SUMMARY PLAN DESCRIPTION September 1, 2025
Health and Welfare Plan
For Construction Workers
ELECTRICAL
INSURANCE
TRUSTEES
SUMMARY PLAN
DESCRIPTION
3
ABOUT THIS SUMMARY PLAN DESCRIPTION
(“SPD”)
This SPD is intended to give you an accurate summary of the benefits and provisions of the Electrical Insurance
Trustees Health and Welfare Plan for Construction Workers (the “Plan”). This SPD and the Trust Agreement contain
a detailed description of the rules, regulations, benefits, and provisions of the Plan. This SPD (and any future
amendments to it) also serves as the ocial Plan document.
Only the Board of Trustees is authorized to interpret the Plan described in this SPD. The Board of Trustees’
interpretation will be final and binding on all persons dealing with the Plan or claiming a benefit from the Plan.
Benefits will be paid only when the Board of Trustees, or persons delegated by them to make such decisions, decides,
in their sole and unrestricted discretion, that the participant or beneficiary is entitled to benefits under the terms
of the Plan. If a decision of the Board of Trustees is challenged in court, it is the intention of the parties that such
decision will be upheld unless it is determined to be arbitrary or capricious. No agent, representative, ocer, or other
person from the Union or an employer has the authority to speak for the Board of Trustees or to act contrary to the
written terms of the governing Plan documents.
This SPD describes benefits that are provided under the Plan. Your eligibility for each benefit is based on whether you
meet the eligibility requirements for a particular benefit. You may not assume you are covered by a benefit because
it is described in this SPD. You may call the Fund Oce if you have questions about your eligibility and benefits.
If you have questions about your eligibility under the Plan or a claim for benefits, only the Executive Director or an
authorized representative are authorized to answer your questions for the Board of Trustees.
The Board of Trustees has full authority to increase, reduce or eliminate benefits and to change any and all provisions
of the Plan at any time and from time to time. The Plan is maintained for the exclusive benefit of its participants and
beneficiaries.
Keep the Fund Oce informed of any changes in the address or contact information for you and your Dependents. It
is your responsibility to ensure that the Fund Oce has an accurate address and contact information for you and your
Dependents. You should also keep a copy, for your records, of any notices you send to or receive from the Plan.
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TABLE OF CONTENTS
SECTION 1: HEALTH & WELLNESS CENTERS AND VISION
CLINIC .............................................................................. 9
1.01 Health & Wellness Centers ........................................ 9
1.02 Vision Center ............................................................ 10
SECTION 2: SCHEDULE OF BENEFITS ............................. 11
SECTION 3: ELIGIBILITY FOR COVERAGE – ACTIVE
EMPLOYEES ..................................................................... 17
3.01 Initial Eligibility Requirements ................................... 17
3.02 Continued Eligibility Requirements............................ 18
3.03 Reciprocity ............................................................... 20
3.04 When Coverage Ends ................................................ 22
3.05 Reinstatement of Eligibility ........................................ 22
3.06 Coverage under the Family and Medical Leave Act .... 22
3.07 Coverage During Military Service .............................. 23
3.08 Suspension of Benefits Due to
Delinquent Employers ............................................... 23
SECTION 4: ELIGIBILITY FOR COVERAGE –
DEPENDENTS ................................................................... 24
4.01 Initial Eligibility Requirements ................................... 24
4.02 Enrolling Dependents for Coverage ........................... 24
4.03 When Dependent Coverage Ends .............................. 25
4.04 Dependent Coverage in the Event of Your Death ........ 25
4.05 Dependent Coverage under a Qualified Medical
Child Support Order .................................................. 25
4.06 Dependent Coverage of a Disabled Child ................... 26
SECTION 5: RETIREE HEALTH BENEFITS ........................ 27
5.01 Eligibility Requirements ............................................ 27
5.02 Dependent Eligibility ................................................. 28
5.03 Retiree Interim Coverage ........................................... 28
5.04 Retiree Self-Pay Contributions .................................. 29
5.05 Retiree Benefit Opt-Out ............................................ 30
5.06 When Retiree Health Benefits End ............................ 30
SECTION 6: CONTINUATION OF HEALTH COVERAGE UNDER
COBRA .............................................................................. 31
6.01 COBRA Coverage at a Glance .................................... 31
6.02 Eligibility for COBRA Coverage .................................. 31
6.03 Types of COBRA Coverage ........................................ 31
6.04 Qualifying Events ...................................................... 31
6.05 Duration of COBRA Coverage .................................... 32
6.06 Cost of COBRA Coverage .......................................... 33
6.07 Payment for COBRA Coverage .................................. 33
6.08 Notification Responsibilities ..................................... 33
6.09 Electing COBRA Coverage......................................... 34
6.10 Termination of COBRA Coverage ............................... 34
6.11 Health Coverage Alternatives .................................... 34
SECTION 7: MEDICAL BENEFITS ...................................... 35
7.01 Calendar Year Deductible .......................................... 35
7.02 Copayments and Coinsurance ................................... 35
7.03 Out-of-Pocket Maximum ........................................... 35
7.04 Preferred Provider Organization (PPO) ...................... 35
7.05 Non-Network Benefits ............................................... 36
7.06 Out-of-Area Benefits ................................................. 36
7.07 Prior Authorization, Case Management
and Utilization Review............................................... 36
7.08 No Surprises Act ....................................................... 39
7.09 Covered Medical Expenses........................................ 40
7.10 Other Covered Medical Expenses .............................. 45
7.11 Medical Expenses not Covered by the Plan ................ 46
SECTION 8: PRESCRIPTION DRUG BENEFITS ................. 49
8.01 Eligibility Requirements ............................................ 49
8.02 Formulary, Generic, Preferred and
Non-Preferred Drugs ................................................ 49
8.03 Out-of-Pocket Maximum ........................................... 49
8.04 Prior Authorization .................................................... 50
8.05 Quantity Limits ......................................................... 50
8.06 Mandatory Generic Drug Program ............................. 50
8.07 Network Pharmacy Program ..................................... 50
8.08 CVS Mail Order and Maintenance Choice Program .... 51
8.09 Specialty Pharmacy Program .................................... 51
8.10 Covered Prescription Drug Expenses ......................... 52
8.11 Non-Covered Prescription Drug Expenses ................. 52
SECTION 9: DENTAL BENEFITS ........................................ 54
9.01 Eligibility Requirements............................................. 54
9.02 Network and Non-Network Providers ........................ 54
9.03 Payment of Dental Benefits ....................................... 54
9.04 Dental Expenses Covered by the Plan ....................... 54
9.05 Dental Expenses Not Covered by the Plan ................. 55
9.06 Orthodontia Services ................................................ 55
SECTION 10: VISION BENEFITS ....................................... 57
10.01 Eligibility Requirements ........................................... 57
10.02 Network and Non-Network Vision Providers ........... 57
10.03 Payment of Vision Benefits ...................................... 57
10.04 Vision Expenses Covered by the Plan ...................... 58
10.05 Vision Expenses Not Covered by the Plan ................ 58
SUMMARY PLAN
DESCRIPTION
5
SECTION 11: HEALTH REIMBURSEMENT
ARRANGEMENT ............................................................... 59
11.01 Eligibility ................................................................. 59
11.02 Suspension of HRA ................................................. 59
11.03 HRA Funding........................................................... 59
11.04 No Vesting of HRAs ................................................. 60
11.05 Crediting of Reciprocal Contributions ...................... 60
11.06 Eligible Expenses and Reimbursements .................. 60
11.07 Reimbursements ..................................................... 61
11.08 Your Right to Opt-Out .............................................. 62
11.09 Forfeiture of HRA Credit Balance ............................ 62
11.10 Payment of HRA Credit Balance upon Your Death.... 62
SECTION 12: DISABILITY BENEFITS ................................ 63
12.01 Disability Related Hour Credits................................ 63
12.02 Limitations and Exclusions ...................................... 63
12.03 Short-Term Disability Benefits ................................. 63
12.04 Long-Term Disability Benefits ................................. 65
12.05 Coordination with Workers’ Compensation Claims ... 67
SECTION 13: MATERNITY LEAVE BENEFITS .................... 70
13.01 Eligibility Requirements .......................................... 70
13.02 When Benefits Begin and End ................................. 70
13.03 Payment of Maternity Leave Benefits ...................... 70
13.04 Maintaining Coverage While on Maternity Leave ...... 70
13.05 Extended Leave Due to Disability ............................ 70
SECTION 14: LIFE INSURANCE BENEFITS ....................... 71
14.01 Eligibility Requirements .......................................... 71
14.02 Designated Beneficiary ........................................... 71
14.03 Accelerated Death Benefit ...................................... 71
14.04 Conversion Privilege ............................................... 72
SECTION 15: ACCIDENTAL DEATH & DISMEMBERMENT
(AD&D) BENEFITS ............................................................ 73
15.01 Eligibility Requirements .......................................... 73
15.02 Safe Driver Benefit .................................................. 73
15.03 Coma Benefit .......................................................... 73
15.04 Education Benefit ................................................... 74
15.05 Transportation Benefit ............................................ 74
15.06 Child Care Benefit ................................................... 74
15.07 Occupational Assault Benefit .................................. 74
15.08 Exclusions .............................................................. 75
SECTION 16: MEMBER ASSISTANCE PROGRAM ............. 76
16.01 Eligibility ................................................................. 76
16.02 Member Assistance Program .................................. 76
SECTION 17: GENERAL PLAN LIMITATIONS AND
EXCLUSIONS .................................................................... 77
SECTION 18: COORDINATION OF BENEFITS ................... 79
18.01 Other Plans Defined ................................................ 79
18.02 Order of Benefit Payment ........................................ 79
18.03 Right to Information and Recovery .......................... 80
18.04 Coordination with Medicare .................................... 80
SECTION 19: REIMBURSEMENT AND SUBROGATION .... 82
19.01 Fund’s Right to Reimbursement .............................. 82
19.02 Subrogation ............................................................ 82
19.03 Plan’s Priority .......................................................... 83
19.04 Failure to Reimburse the Plan ................................. 83
19.05 Your Responsibilities ............................................... 84
19.06 Claims for Attorney’s Fees Against the Plan ............. 84
SECTION 20: FRAUDULENT CONDUCT
BENEFIT POLICY .............................................................. 85
20.01 General Provisions .................................................. 85
20.02 Possible Offenses and Associated Harm
or Loss to the Plan .................................................... 85
SECTION 21: CLAIMS AND APPEALS PROCEDURES ....... 86
21.01 General Provisions .................................................. 86
21.02 Definition of a Claim ................................................ 86
21.03 Initial Claim Filing Deadline ..................................... 87
21.04 How to File a Claim ................................................. 87
21.05 Claims Processing Timeframes ............................... 90
21.06 Notice of Initial Decision ......................................... 92
21.07 Appealing the Denial of an Internal Claim ................ 93
21.08 Timing of Notice of Decision on Internal Appeal ....... 94
21.09 Notice of Decision on Internal Appeal ...................... 95
21.10 External Appeal Process ......................................... 96
21.11 Physical Examination .............................................. 98
21.12 Authorized Representatives .................................... 98
21.13 Benefit Payment to an Incompetent Person ............. 99
21.14 Misrepresentation or Falsification by Participant ..... 99
21.15 Prohibition of Rescission ......................................... 99
SECTION 22: YOUR ERISA RIGHTS .................................. 100
22.01 Receive Information about Your Plan and Benefits .. 100
22.02 Continuing Group Health Plan Coverage .................. 100
22.03 Prudent Actions by Plan Fiduciaries ........................ 100
22.04 Enforcement of Your Rights ..................................... 100
22.05 Assistance with Your Questions ............................... 101
SECTION 23: YOUR HIPAA RIGHTS .................................. 102
23.01 Privacy Policy ......................................................... 102
23.02 Use and Disclosure of Protected
Health Information (PHI) ........................................... 102
6
SECTION 24: IMPORTANT PLAN INFORMATION ............. 105
24.01 Plan Name .............................................................. 105
24.02 Board of Trustees .................................................... 105
24.03 Plan Administrator and Sponsor .............................. 105
24.04 Plan Number .......................................................... 106
24.05 Employer Identification Number.............................. 106
24.06 Plan Year ................................................................ 106
24.07 Amendment and Termination of the Plan ................. 106
24.08 Plan Funding ........................................................... 106
24.09 Collective Bargaining Agreement ............................ 106
24.10 Agent for Service of Legal Process .......................... 107
24.11 Non-Assignment of Benefits .................................... 107
24.12 Trustee Authority and Interpretation........................ 107
24.13 Severability Clause .................................................. 107
24.14 Pronouns ................................................................ 108
24.15 Recovery of Benefits Paid in Error ........................... 108
24.16 Governing Law ........................................................ 108
24.17 For More Information............................................... 108
SECTION 25: GLOSSARY .................................................. 109
SUMMARY PLAN
DESCRIPTION
7
IMPORTANT CONTACT INFORMATION
Electrical Insurance Trustees Fund Office (“Fund Office”)
6195 West 115th Street
Alsip, IL 60803
(312) 782-5442
Health and Wellness Center – Premise Health
6195 West 115th Street
Suite A
Alsip, IL 60803
(312) 262-7002
4179 Dundee Road,
Suite A106
Northbrook, IL 60062
(847) 402-2300
Vision Center – VSP
6195 West 115th Street
Suite B
Alsip, IL 60803
(312) 795-5841
Medical, Dental & Behavioral Health & Substance Abuse Benefits
Blue Cross Blue Shield of Illinois
Medical & BHSA:
P.O. Box 660603
Dallas, TX 75266-0603
Dental:
c/o DNoA
P.O.Box 660247
Dallas, TX 75266-0247
Customer Service: (800) 862-3386
TTY Only Customer
Service:
(800) 526-0844
Voice Assisted
Customer Service:
(800) 526-0857
PPO Provider Finder: (800) 810-2583
Pre-Authorization/
Pre-Certification:
(800) 635-1928
24/7 Nurse Help Line: (800) 299-0274
Dental & Orthodontia: (800) 862-3386
Behavioral Health/
Substance Abuse
Customer Service
(800) 851-7498
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Prescription Drug Benefits
CVS Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136
Customer Service (800) 566-5693
Pharmacist Help Line (800) 345-5413
Mail Order Prescription
Services
(800) 566-5693
Specialty Pharmacy
Customer Care
(800) 237-2767
Specialty Pharmacy
Prescription Fax
(800) 323-2445
Member Assistance Program (MAP)
Employee Resource Systems, Inc. (ERS)
No claim forms required
24/7 Assistance
Program
(800) 292-2780
Vision Benefits
Vision Service Plan (VSP)
Online claim forms Customer Service (800) 877-7195
Submit out-of-network claim forms at www.vsp.com
Life Insurance and AD&D Benefits
Voya Financial
Kocher Group Customer Service (888) 212-7882
Health Reimbursement Arrangement (HRA)
WageWorks/HealthEquity
P.O. Box 14053
Lexington, KY, 40512
Customer Service (877) 924-3967
Card Activation (866) 296-2852
SUMMARY PLAN
DESCRIPTION
9
SECTION 1: HEALTH & WELLNESS CENTERS AND
VISION CLINIC
If you are an Active Employee or Retiree and you and your eligible Dependents are eligible for health benefits under
the Plan, you may access services provided by the Health & Wellness Centers and the Vision Clinic.
1.01 Health & Wellness Centers
The Health & Wellness Center, operated by Premise Health, provides a comprehensive range of healthcare services,
including primary care, care management, lab services, vaccinations, physical therapy, chiropractic and mental
health services at no cost to you or your eligible Dependents.
The Health & Wellness Centers are staed by experienced Physicians, nurse practitioners, physical therapists,
chiropractors and behavioral health specialists. The Health & Wellness Centers are open Monday through Friday and
located at the following addresses:
Please contact the Health and Wellness Centers to schedule an appointment, or you can download the My Premise
Health app and schedule an appointment.
EIT Health & Wellness Center –
Alsip
6195 W. 115th Street
Suite A
Alsip, Illinois 60803
(312) 262-7002
Monday, Tuesday,
Wednesday, Friday
8 a.m. – 5 p.m.
Thursday
10 a.m. – 7 p.m.
Premise Health Wellness Center –
Northbrook
4179 Dundee Road
Suite A106
Northbrook IL 60062
(847) 402-2300
Monday, Tuesday,
Thursday, Friday
8 a.m. – 5 p.m.
Wednesday
9 a.m. – 6 p.m.
10
1.02 Vision Center
The Vision Center in Alsip, operated by VSP, is staed by a skilled optometrist and knowledgeable opticians who are
dedicated to providing you with a first-class experience. While the Plan’s copayments and coinsurance do apply at
the Vision Center, the Vision Center oers a large selection of frames that are within the vision benefit allowance and
a personalized experience to be shared only by other Plan Participants and their eligible Dependents.
Some of the services provided at the Vision Center include the following:
• WellTech Exam: Delivers a more accurate eye health exam and vision Rx.
• WellTech Fit: One photo provides precise measurements to customize your prescription to fit your frame.
• FREE Retinal Imaging: Assess eye health and provide an eye health history. It can also help in identifying other
underlying health issues such as diabetes and high blood pressure.
• Kids’ Worry-Free Glasses: Guaranteed for one year including breaks, damage and loss.
• FREE Adjustments: Custom fit or realign any eyewear, regardless of where it was purchased.
• 90-Day Guarantee: If you need to change frames, lenses, or both during the first 90 days, the clinic will assist you
and make the changes at no charge.
• Large selection of glasses and safety glasses for you and your eligible Dependents.
EIT Vision Clinic
6195 W. 115th Street
Suite B
Alsip, Illinois 60803
(312) 795-5841
Monday, Tuesday,
Wednesday, Friday
8 a.m. – 5 p.m.
Thursday
10 a.m. – 7 p.m.
Call (312) 795-5841 or visit www.vsponsiteclinic.com/eit
to make an appointment.
SUMMARY PLAN
DESCRIPTION
11
SECTION 2: SCHEDULE OF BENEFITS
In general, the level of coverage the Plan provides diers depending on whether treatment is provided by Network
Providers versus Non-Network Providers, as shown in the schedule below. Network Providers are providers who
participate in a Preferred Provider Organization (PPO) by agreeing to accept certain negotiated rates for services
provided. The Plan contracts with a PPO to provide Participants with access to Network Providers. Non-Network
Providers do not participate in a PPO network and do not have an agreement to accept negotiated rates. This means
that if you visit a Non-Network Provider, it may cost more, and you may be responsible for amounts above what the
Plan allows for a service.
The Plan pays a percentage of the Eligible Charges, as shown in the chart below, for covered medical expenses.
The Eligible Charge diers depending on if the service is being performed by a Network Provider or Non-Network
Provider.
You are responsible for paying for the following: Deductibles, Copayments, your share of Eligible Charges (including
charges that are more than the Eligible Charges when you use a Non-Network Provider), any amount over a
maximum benefit, and any expenses that are not covered by the Plan. Please refer to each section for further details
about specific service coverage and limitations or contact the Fund Oce or the appropriate healthcare provider.
Medical Benefits: What You Pay Network Non-Network
Calendar Year Deductible –
Does not apply to Network Preventive
Services; Emergency Services;
Chiropractic Services; Physical, Speech
and Occupational Therapy Services; and
Hearing Aid Benefit
$600 per person
$1,200 per family
Medical Out-of-Pocket Maximum –
Includes Deductibles, Oce Visit Copays,
and Coinsurance Payments, but excludes
Prescription Drug Copayments
$3,000 per person/family $5,000 per person/family
Medical Benefits: What the Plan Pays Network Non-Network
Oce Visits
Physician Office Visits 100% after $25 copay 80%
Specialist Office Visits 100% after $60 copay 80%
Chiropractor and Naprapathy Services –
30 visit limit per person, per calendar year
90% 80%
Acupuncture Services – 30 visit limit per
person, per calendar year
90% 80%
Routine Physical Examination – One exam
per person, per calendar year
100% 80%
12
Routine Coronary Artery Scan – One exam
per person, per calendar year
90% 80%
Routine Immunizations – Dependent
Children under age 19
100% 80%
Routine Immunizations – Participants and
Dependents over age 19
100% 80%
Other Preventive Services
(as required by federal law)
100% 80%
Urgent and Emergency Care
Urgent Care Center 90% 80%
Emergency Services 90%
90% of the lesser of the amount
billed or the QPA
Emergency Medical Transportation 80% of Billed Charges
Hospitalization
Facility 90% 80%
Physician/Surgeon 90% 80%
Prior Authorization Review is required for Inpatient admissions, for more information see Section 7.07.
Outpatient Services
Outpatient Surgery 90% 80%
Physical Therapy – 30 visit limit per
person, per diagnosis, per calendar year
90% 80%
Speech Therapy – 30 visit limit per person,
per diagnosis, per calendar year
90% 80%
Occupational Therapy – 30 visit limit per
person, per diagnosis, per calendar year
90% 80%
Mental and Substance Abuse Disorder Services
Inpatient Care 90% 80%
Outpatient Care 100% after $15 copay 80%
Structured Intensive Outpatient
Substance Abuse Program
100% after $15 copay 80%
Prior Authorization Review is required for Inpatient admissions, for more information see Section 7.07.
Laboratory and Imaging Services
Laboratory Services – Such as x-rays and
blood work
90% 80%
Diagnostic Imaging – Such as CT scans,
PET scans and MRIs
90% 80%
SUMMARY PLAN
DESCRIPTION
13
Home Healthcare and Hospice Services
Skilled Nursing Facility 90% 80%
Home Healthcare 90% 80%
Hospice Care 90% 80%
Pregnancy and Delivery
Prenatal and Postnatal Office Visits –
Does not include laboratory and imaging
100% after $25 copay 80%
Delivery and Inpatient Services 90% 80%
Fertility Treatment – $15,000 combined
lifetime maximum for Participants and
Dependent spouse only
90% 80%
Hearing Benefits
Exam – One exam per person, per
calendar year
$75
Hearing Aids – Maximum two (2) hearing
aids per person, per ear once every 60
months
80% up to $2,500 per hearing aid
Limits do not apply to bone anchored hearing aids for eligible Dependent Children under the age 19.
Other Care and Expenses
Prosthetic Devices, Casts and Splints 90% 80%
Durable Medical Equipment 90% 80%
All Other Covered Expenses 90% 80%
Prescription Drug Benefits: What You Pay Network Pharmacy
Prescription Drug Out-of-Pocket Maximum
Includes prescription drug copayments;
excludes all medical expenses.
Subject to change each Calendar Year
$6,200 per person/family
Fertility Treatment
$15,000 lifetime combined maximum
for Participant and Dependent spouse only
Retail Pharmacy – 30-day supply; two (2) fill limit on maintenance/long-term prescriptions
Generic $10 copay
Preferred Brand
25% of cost
($30 minimum copay; $50 maximum copay)
Non-Preferred Brand
30% of cost
($50 minimum copay; $100 maximum copay)
14
Maintenance Choice Mail-Order or CVS Pharmacy –
90-day supply; no fill limit; maintenance/long-term prescriptions only
Generic $20 copay
Preferred Brand
25% of cost
($60 minimum copay; $100 maximum copay)
Non-Preferred Brand
30% of cost
($100 minimum copay; $200 maximum copay)
Prescription drugs purchased at a Non-Network Pharmacy are not covered under the Plan. Specialty Drugs must
be purchased through the Specialty Pharmacy Program. The copay amount for specialty drugs are the preferred
brand or non-preferred brand copays, as shown above, unless Prudent Rx copay assistance applies.
Dental Benefits: What the Plan Pays Network
Non-Network
(based on U&C Charges)
Maximum Benefit $3,000 per person, per
calendar year (excludes orthodontia)
80% 80%
The calendar year dental benefit maximum does not apply to diagnostic and preventive services for
Dependent Children under age 19.
Dental Services
Diagnostic and Preventive Services 100% 100%
Basic and Major Services 80% 80%
Orthodontia Services – $4,000 per person
lifetime maximum
80% 80%
Surgical Removal of Complete Bony
Impacted Teeth – $3,500 per person
lifetime maximum
80% 80%
The lifetime orthodontia maximum does not apply to Medically Necessary expenses for eligible Dependent
Children under age 19.
Vision Benefits: What the Plan Pays Network
Non-Network
(based on Billed Charges)
Exams
Adults – One exam per calendar year 100% after $30 copay
100% up to $45 maximum after
$30 copay
Dependent Children under age 19 – One
exam per calendar year
100% 100% after $30 copay
SUMMARY PLAN
DESCRIPTION
15
Lenses
Adults 100% after $20 copay
100% up to specified maximums
• $37 single vision
• $60 lined bifocal
• $75 lined trifocal &
progressive after $20 copay
Dependent Children under age 19 100% after $20 copay 80% after $20 copay
Frames
Adults
100% after $30 copay up to
specified maximums:
• $225 featured frame brands
allowance; or
• $175 standard frame
allowance; or
• $175 frame allowance at
Walmart or Sam’s Club; or
• $95 frame allowance at
Costco
Plus 20% savings on the amount
over allowance
100% up to $60 maximum after
$30 copay
Dependent Children under age 19 100% after $20 copay 80% after $20 copay
Contact Lenses
Adults 100% up to $200 maximum 80% up to $200
Dependent Children under age 19 100% 80%
Participant Annual Limit: Two pairs of framed lenses or two sets of contact lenses or one of each per calendar
year limit.
Dependent Annual Limit: One pair of framed lenses or one pair of contact lenses per calendar year limit.
Maternity Leave Benefits: What the Plan Pays
Weekly Benefit $800 per week up to a maximum of 26 consecutive weeks
Participants are credited with 5 hours per day, up to a maximum of 25 hours per week for each week of Maternity
eligibility to maintain coverage under the Plan.
Short-Term Disability Benefit: What the Plan Pays
Weekly Benefit $750 per week up to a maximum of 13 consecutive weeks
Participants are credited with 5 hours per day, up to a maximum of 25 hours per week for each week of Short-
Term Disability eligibility to maintain coverage under the Plan.
16
Long-Term Disability Benefit: What the Plan Pays
Monthly Benefit
60% of average monthly pay for the previous 12 months
($2,000 minimum; $3,000 maximum)
Benefit will be reduced by any disability benefits paid or payable by Social Security. Participants are credited
with 5 hours per day, up to a maximum of 25 hours per week for each week of Long-Term Disability eligibility to
maintain coverage.
Life Insurance and Accidental Death & Dismemberment Benefit: What the Plan Pays
Life Insurance $20,000
Accidental Death $10,000
Accidental Dismemberment $10,000
Covered Loss
• Loss of both hands, both feet, or the
sight of both eyes
• Loss of one hand and one foot
• Loss of hearing in both ears and
speech
• Loss of one hand, or one foot and the
sight of one eye
• Quadriplegia (paralysis of both upper
and both lower limbs)
$10,000
• Loss of one hand or one foot or sight of
one eye
• Paraplegia (paralysis of both lower
body limbs)
• Hemiplegia (paralysis of the one arm
and one leg on the same side of the
body)
$5,000
• Loss of speech
• Loss of hearing in both ears
• Loss of a thumb and index finger on
the same hand
$2,500
Member Assistance Program: What the Plan Pays
Telephonic Counseling Sessions Unlimited
Face-to-Face Counseling Sessions 3 sessions per problem, situation or issue
SUMMARY PLAN
DESCRIPTION
17
SECTION 3: ELIGIBILITY FOR COVERAGE – ACTIVE
EMPLOYEES
3.01 Initial Eligibility Requirements
You will become eligible for coverage under the Plan on the first day of the month following a period of six consecutive
months during which you accumulate at least 600 Contributed Hours. Hours earned at the Apprentice School are
counted as Contributed Hours for purposes of meeting this eligibility requirement.
Your initial eligibility will continue for the remainder of the applicable Coverage Quarter, and then you must satisfy the
Continued Eligibility Requirements to maintain eligibility for coverage under the Plan.
For Example – Initial Eligibility
Work Period Contributed Hours
Cumulative
Contributed Hours Coverage Period Date
May 75 75 Not Eligible
June 120 195 Not Eligible
July 100 295 Not Eligible
August 130 425 Not Eligible
September 105 530 Not Eligible
October 130 660
*Eligible November 1st
through December 31st
*Note: Contributed Hours for October are not reported to the Fund Oce until November 15th.
If you do not accumulate 600 Contributed Hours during the initial period of six consecutive months, the Fund Oce
will roll the work period forward by one month. The work period will continue to roll forward one month at a time until
you accumulate 600 Contributed Hours.
For Example – Initial Eligibility
Work Period Contributed Hours
Cumulative Contributed
Hours Coverage Period Date
May – October 500 500 Not Eligible
June –
November
80 580 Not Eligible
July – December 120 700
*Eligible January 1st
through March 31st
*Note: Contributed Hours for December are not reported to the Fund Oce until January 15th.
18
3.02 Continued Eligibility Requirements
Generally, once you meet the Initial Eligibility Requirements, you will remain eligible for subsequent Coverage
Quarters as long as you accumulate at least 300 Contributed Hours during the most recent Review Quarter. If you do
not accumulate 300 Contributed Hours during the most recent Review Quarter, you may be eligible to continue your
coverage under the 1,200 Hour Rule or by making self-payments as explained below.
300 Hour Rule
Once you meet the Initial Eligibility Requirements, you will remain eligible for subsequent Coverage Quarters if you
accumulate at least 300 Contributed Hours during the Review Quarter that corresponds to the Coverage Quarter as
follows:
Review Quarter Coverage Quarter
January, February, March July, August, September
April, May, June October, November, December
July, August, September January, February, March
October, November, December April, May, June
1,200 Hour Rule
If you do not meet the 300 Hour Rule explained above, you will remain eligible for subsequent Coverage Quarters if
you accumulate at least 1,200 Contributed Hours during the four Review Quarters that corresponds to the Coverage
Quarter as follows:
Four Review Quarters Coverage Quarter
April 1st – March 31st July, August, September
July 1st – June 30th October, November, December
October 1st - September 30th January, February, March
January 1st – December 31st April, May, June
The Fund Oce reviews your work history four (4) times a year to determine if you have met the 300 Hour Rule or the
1,200 Hour Rule to continue your coverage.
SUMMARY PLAN
DESCRIPTION
19
Month
of Review
Coverage
Quarter
Review
Quarter
Four Review
Quarters
Coverage
Through Month
(If hour
requirement met)
Cancellation
Month
(If hour
requirement
not met)
November
January, February,
March
July, August,
September
October 1st –
September 30th March 31st December 31st
February April, May, June
October,
November,
December
January 1st –
December 31st June 30th March 31st
May
July, August,
September
January, February,
March
April 1st –
March 31st September 30th June 30th
August
October,
November,
December April, May, June
July 1st –
June 30th December 31st September 30th
Self-Payments
If you do not meet the Continued Eligibility Rules as described above, you may be eligible to continue your coverage
under the Plan by making self-payments. The Fund Oce will notify you if you are eligible to continue coverage
through self-payments.
To qualify for self-payment, you must meet the following requirements:
• Your Covered Employment was terminated involuntarily due to lack of work or reduction in work force. You will not
be eligible if such a reduction or lack of work is due to a voluntary quit or a discharge due to misconduct.
• You are registered with the Union Referral Hall or Apprentice School as available for work during the Review
Quarter and are compliant with Referral Hall procedures.
• You have not exceeded three (3) consecutive Coverage Quarters of self-payment.
Submitting Self-Payment
All self-payments are due by the date indicated in the self-payment notice from the Fund Oce. All payments are due
by the date indicated, and no payment will be accepted after the due date. The Fund Oce will accept checks or money
orders as a form of payment. Cash, credit card or debit card payments will not be accepted; partial or installment payments
will also not be accepted.
If eligible, the amount of your self-payment is equal to the number of hours you have fallen short of the 300 Hour Rule
or the 1,200 Hour Rule, whichever is less, multiplied by the current Principal or Residential Agreement’s health and
welfare contribution rate.
All self-payments must be postmarked no later than the 15th day of the month prior to termination. You will be
notified by mail. If you fail to make a timely self-payment or are no longer eligible to make a self-payment, your
eligibility will terminate at the end of the applicable Coverage Quarter.
20
Disability Related Hour Credits
If you are unable to work because of a certified disability, you may be eligible to receive disability-related hour
credit(s) that count toward the eligibility requirements for the Plan for each week of disability. For more information,
including requirements to earn disability-related hour credits, please see Section 12.01.
3.03 Reciprocity
If you work partly in another IBEW jurisdiction under a reciprocity agreement and you wish to maintain your eligibility
under the Plan, your employer’s health and welfare contributions on your behalf to the other fund (the “traveling
fund”) must be transferred to the Plan.
To do this, you must register your reciprocity authorization with the Electronic Reciprocal Transfer System
(ERTS) in the jurisdiction where the work is to be performed. You should register before you begin work in another
jurisdiction, as only the health and welfare contributions made based on the number of hours worked after the date
you register on ERTS are transferred to the Fund Oce.
It generally takes a minimum of six (6) -to eight (8) weeks before health and welfare contributions from another
jurisdiction are submitted to the Fund Oce. Please remember that it is your responsibility to keep track of
your reciprocated hours. If there is a discrepancy between the number of hours worked and the number of hours
reciprocated to the Fund Oce, you must contact the traveling fund (or local union) where the work was performed
to resolve any issues. When you are working in another jurisdiction, you are subject to that jurisdiction’s collective
bargaining agreement.
If you do not arrange to have your employer’s health and welfare contributions transferred to the Plan, hours
worked in another jurisdiction will not be eligible for credit in determining whether you meet the Continued Eligibility
Requirements for coverage under the Plan.
To be eligible for hour for hour credit while working for other jurisdictions, you must have worked a minimum of 1,040
contributed hours under the Principal Agreement, Residential Agreement or a similar agreement negotiated in the
following IBEW collar county Local Unions: Locals 9, 117, 127, 150, 176, 196, 364, 430, 461, 531, 697, and 701
during the 36 months immediately preceding the work month health and welfare contributions are made,
If you do not meet the minimum hour requirement in the 36 months immediately preceding the work month
contributions are made, then your hours will be prorated to reflect the dierence in the health and welfare
contribution rates between the locals. This means your contributed health and welfare hours will be calculated by
dividing the other local’s health and welfare contribution rate by the Local 134 health and welfare contribution rate
under the Principal or Residential Agreements.
The Board of Trustees has the authority to add and/or remove additional locals to which the exception applies on a
temporary or permanent basis.
SUMMARY PLAN
DESCRIPTION
21
For Example – Reciprocity:
Local 134 Principal/Residential Health and Welfare Contribution Rate: $17.06
Local 58 Health and Welfare Contribution Rate: $9.75
Hours worked in Local 58 for June: 100
Total hours reported in Local 58 in the last 36 months: 980
Total hours reported in Local 134 and/or prorated Locals in last 36 months: 2,010
Prorated Reciprocated Hours for June: 57
Assume you have been traveling in Local 58 for the last four (4) years and have worked 100 reciprocated hours.
Your reciprocated hours are prorated because you have not earned the minimum of 1,040 hours in Local 134 and/
or a similar agreement negotiated in the collar county area in the prior 36 months. You will be credited with 57
reciprocated hours toward continuing your coverage under the Plan. This amount is calculated by dividing Local
58’s current health and welfare contribution rate of $9.75 by Local 134’s current health and welfare contribution
rate of $17.06 and multiplying the result by the 100 hours worked in Local 58.
$9.75 ÷ $17.06 =.57 x 100 worked hours = 57 prorated reciprocated hours
If your reciprocated health and welfare hours are prorated and you have insucient Contributed Hours to maintain
your eligibility under the Plan solely because of such proration, you can make self-payments for the number of hours
you are short due to proration of your reciprocated health and welfare hours to continue coverage under the Plan.
These self-payments will be required at Local 134’s health and welfare contribution rate in eect at the time of such
self-payment and will extend your coverage for you and your Eligible Dependents for the coverage quarter. You must
be Registered with the Union Referral Hall or Apprentice School and be Available for Work during the Review Quarter
and are compliant with Referral Hall procedures.
If you fail to make your self-payment timely, your coverage under the Plan will terminate, and you will be oered
COBRA Continuation coverage.
In the event the contribution rate of the traveling fund is lower than Local 134’s contribution rate and it is dicult
for you to continue your eligibility under the Plan because of these proration rules, you can request a temporary
or permanent cessation of transfer of health and welfare contributions through the ERTS system. By making this
request, health and welfare contributions earned under the traveling fund will no longer be transferred back to the
Plan. While you run out your eligibility under the Plan, you can begin earning hours under the traveling fund and work
toward establishing eligibility under the traveling fund. Once you stop transferring contributions back to the Plan, the
traveling fund is obligated to keep your health and welfare contributions so you can work to gain eligibility under the
traveling fund.
If you later decide that you want to return to the Plan, you would be able to take the same actions and work to gain
eligibility under the Plan while you run out your eligibility under the traveling fund.
Additionally, your HRA contributions may be impacted when you work for reciprocal locals who have a health and
welfare contribution rate that is equal to or less than the Local 134 health and welfare contribution rate. See Section
11.05 for further details on how this is determined.
22
3.04 When Coverage Ends
Your coverage under the Plan as an Active Employee ends when the first of the following occurs:
• You fail to meet the Continued Eligibility Requirements; or
• Your employer fails to make the required contributions to the Plan on your behalf; or
• You retire (unless you are running out your Active Employee coverage based on Contributed Hours); or
• You die; or
• You become eligible under another welfare plan administered by the Board of Trustees; or
• The Board of Trustees terminates the Plan for any reason.
Insucient Contributed Hours
It is your responsibility to know when your coverage will end due to insucient Contributed Hours. Advance notice of loss of
coverage from the Fund Oce is not an obligation of the Fund, its Trustees or the Fund Oce.
Coverage termination will be prospective unless you (or a person seeking coverage under the Plan as an Eligible
Dependent) perform an act, practice, or omission that constitutes fraud, or makes an intentional misrepresentation of
material fact, as prohibited by the terms of the Plan.
3.05 Reinstatement of Eligibility
If you lose coverage under the Plan, you may reinstate your eligibility on the first day of the month following a period
of three-consecutive months during which you accumulate 300 Contributed Hours after the date you lost your
coverage. Once you reinstate your eligibility, your coverage will continue for the remainder of the corresponding
Coverage Quarter. To continue to maintain eligibility thereafter, you must meet the Continued Eligibility
Requirements.
For Example – Reinstatement of Eligibility: Assume you failed to meet the Continued Eligibility Requirements and
your coverage under the Plan ended September 30th. From October 1st through December 31st, you accumulated
400 Contributed Hours. You are therefore eligible for coverage under the Plan from January 1st through March 31st
(remainder of the Coverage Quarter). You have also met the Continued Eligibility Requirements based on the 300
Hour Rule (Review Quarter: October - December), so you will continue to be eligible from April 1st through June 30th.
Eligibility for coverage after June 30th will depend on whether the Continued Eligibility Requirements are met.
If you do not qualify for reinstatement within 52 weeks of the date your eligibility under the Plan ended, you must
meet the Initial Eligibility Requirements under the Plan.
3.06 Coverage under the Family and Medical Leave Act
Under the Family and Medical Leave Act of 1993 (“FMLA”), you may qualify to take up to 12 weeks of unpaid leave
during any 12-month period for one or more of the following reasons:
• Birth and care of a newborn child; or
• Placement of a child with you for adoption or foster care; or
• Care of your spouse, child or parent with a serious health condition; or
• A serious health condition that prevents you from performing your job; or
• A qualifying exigency because your spouse, parent or child is on covered active duty or called to covered active-
duty status as a member of the National Guard, Reserves, or Regular Armed Forces.
SUMMARY PLAN
DESCRIPTION
23
In addition, you may also qualify to take up to 26 weeks of unpaid leave during any 12-month period to care for a
spouse, child, parent or next of kin who is a covered service member suering from a serious injury or illness incurred
while on covered active military duty.
Your eligibility for FMLA leave will be determined by your employer. You are generally eligible for leave under FMLA if
your employer approves and you meet the following criteria:
• You worked at least 12 months for a participating employer; and
• You have at least 1,250 hours of contributions within the last 12 months from the leave starting date.
If you would like to take an FMLA leave of absence, you must notify your employer and the Fund Oce. Should your
employer grant your request for leave under FMLA, you will receive five (5) hours of credit for each day you are on
FMLA leave. For more information about FMLA or if you have any questions, please contact the Fund Oce.
3.07 Coverage During Military Service
If you are on a military leave of absence under the Uniformed Services Employment and Reemployment Rights Act
(“USERRA”), your coverage and your Dependents’ coverage will continue under the Plan.
You must provide the Fund Oce with a copy of your military orders that gives both a report date and a discharge
date. You will receive five (5) hours of credit for each day you are on military leave. For additional information about
coverage during a military leave of absence, contact the Fund Oce.
3.08 Suspension of Benefits Due to Delinquent Employers
If your employer has not submitted contributions for the hours you worked, coverage for you and your covered
Dependents will be suspended under the Plan if you continue working for that employer while the employer is
delinquent.
Your coverage under the Plan will be retroactively reinstated once your employer is in compliance with the Collective
Bargaining Agreement or if you stop working for that employer. You must stop working for that employer and sign the
out-of-work list at the Referral Hall within seven (7) days after being notified of your suspension of benefits.
Suspension of benefits is not a Qualifying Event as defined under COBRA. This means you and your covered
Dependents are not entitled to COBRA coverage solely because your coverage under the Plan is suspended. For
more information on COBRA coverage, see Section 6.
24
SECTION 4: ELIGIBILITY FOR COVERAGE –
DEPENDENTS
4.01 Initial Eligibility Requirements
Generally, your Dependent(s) become eligible for coverage on the date you become eligible, or, if later, on the date
he or she meets the definition of Dependent under the Plan. For Dependent eligibility for Retiree Health Benefits, see
Section 5.02.
4.02 Enrolling Dependents for Coverage
Once you are eligible for coverage under the Plan, you may choose to add your eligible Dependents. To add an eligible
Dependent to the Plan, you must submit the following supporting documentation:
Eligible Dependents Required Documentation
Spouse
• Copy of the court certified marriage certificate
• Copy of court certified birth certificate
• Copy of Social Security card
• Health insurance information, if spouse is covered under
another plan for purposes of coordination of benefits.
Children (under age 26)
For All Children:
• Copy of court certified birth certificate or legal paternity test
• Copy of Social Security card
Stepchildren:
• Copy of court certified marriage certificate
• Copy of court certified birth certificate, which must contain
name of the child’s parent listed on marriage certificate
Adopted Children (or children placed in your home for adoption):
• Copy of final adoption papers or interim court order
Qualified Medical Child Support Order (QMCSO)
• Copy of court decree verifying obligation to provide medical
benefits for a dependent child
Note: Newborns will be covered for the first 30 days following
birth without a birth certificate. After 30 days, coverage will be
suspended without the required documentation listed above. Once
all documents have been received, benefits will be retroactively
reinstated to the date of suspension.
SUMMARY PLAN
DESCRIPTION
25
Disabled Children (age 26 and older)
In addition to the required documents listed above for Children
under age 26:
• Proof of disability, including diagnosis and treatment by a
Physician
• Proof of financial dependency, including tax filing documents
Note: You may be requested to periodically provide proof of
continued disability.
Please note that Federal law requires all Active Employees and eligible Dependents to provide a Social Security
number for tax reporting purposes. Your coverage will be suspended if Social Security numbers are not received by
the Fund Oce within 90 days of the coverage eective date and will be retroactively reinstated if such information
is received within 12 months. If such information is received more than 12 months from the coverage eective date,
coverage will be reinstated no earlier than 12 months prior to the date the information is received.
4.03 When Dependent Coverage Ends
Your Dependent’s coverage will end on the earliest of the following to occur:
• The date your eligibility under the Plan ends for a reason other than death; or
• The date he or she no longer meets the definition of a Dependent under the Plan; or
• The date you become eligible under another plan administered by the Board of Trustees; or
• The date the Board of Trustees terminates Dependent benefits under the Plan for any reason.
4.04 Dependent Coverage in the Event of Your Death
After the date of your death, your surviving Dependent(s) will remain eligible for coverage under the Plan for 36
months beginning with the month following the date of your death. Dependents are not subject to the Retiree Self-
Pay. Once that period passes, your Dependent(s) may elect COBRA coverage.
4.05 Dependent Coverage under a Qualified Medical Child Support Order
A Qualified Medical Child Support Order (QMCSO) is a judgment, decree or order issued under a state domestic
relations law by a court or an administrator that requires a parent to provide medical support to a child.
The Fund will honor the terms of a QMCSO regarding communication with the custodial parent of a Dependent
and with regard to which plan is primary when a Dependent is covered by more than one group health plan for the
purposes of the Plan’s coordination of benefits rules.
The Fund Oce will notify you if a QMCSO is received. You may request a copy of the Fund’s QMSCO procedures,
free of charge, if you need additional information.
26
4.06 Dependent Coverage of a Disabled Child
If your Child is age 26 or older and disabled, his or her coverage may be continued under the Plan. To continue
coverage, the Child must have been diagnosed with a severe physical or mental disability and the disability is
expected to last for a continuous period of 12 or more months or more, provided:
• Such incapacity began before the end of the month the Child attains age 19; and
• The Child was covered by the Plan on the day prior to his or her 19th birthday; and
• The Child is dependent on you for more than 50% of his or her financial support and maintenance for the
calendar year; and
• The Child resides in your home; and
• The Child’s disability is not solely due to alcoholism or drug addiction; and
• You (the Participant) remain eligible for coverage under the Plan.
You must provide proof of the mental or physical disability no later than 30 days prior to the date coverage would end
because the Child attains age 26.
The Fund may also require you to provide proof of the disability periodically. Contact the Fund Oce for more
information on how to continue coverage for a Child with a serious disability.
SUMMARY PLAN
DESCRIPTION
27
SECTION 5: RETIREE HEALTH BENEFITS
5.01 Eligibility Requirements
You are eligible for Retiree Health Benefits under the Plan if (1) you retire on a disability pension, you retire with a 60
and Out Pension, or you attain age 62, and (2) you meet the following requirements under the 15-Year Rule, 20-Year
Rule, 25-Year Combined Service Rule, or the 30-Year Rule as follows. Note that the eective date of your retirement
benefit under Pension Plan No. 2 is your “Retirement Date.”
The 15-Year Rule
You are eligible for Retiree Health Benefits under the 15-Year Rule if you meet all the following criteria:
• You are receiving a retirement benefit from and have at least 15 years of Credited Service earned after
December 31, 1976, under Pension Plan No. 2;
• You began earning Credited Service under Pension Plan No. 2 before January 1, 2023, which Credited Service
was not cancelled by a permanent break in service;
• You have been covered as an Active Employee under the Plan throughout the two (2) years before your Pension
Plan 2 Retirement Date; and
• You continuously pay the applicable retiree self-pay contributions as required under the Plan.
The 20-Year Rule
You are eligible for Retiree Health Benefits under the 20-Year Rule if you meet all the following criteria:
• You are receiving a retirement benefit from Pension Plan No. 2 and have at least 20 years of Credited Service
earned under Pension Plan No. 2;
• You began earning Credited Service under Pension Plan No. 2 on or after January 1, 2023;
• You have been covered as an Active Employee under the Plan throughout the two (2) years before your Pension
Plan 2 Retirement Date; and
• You continuously pay the applicable retiree self-pay contributions as required under the Plan.
The 25-Year Combined Service Rule
You are eligible for Retiree Health Benefits under the 25-Year Combined Service Rule if you meet all the following
criteria:
• You are receiving a retirement benefit from and have a combined total of at least 25 years of Credited Service
under Pension Plan No. 2 and Pension Plan No. 4 (with a minimum of at least 10 of those years of Credited
Service earned under Pension Plan No. 2);
• You have been covered as an Active Employee under the Plan throughout the two (2) years before your Pension
Plan 2 Retirement Date; and
• You continuously pay the applicable Retiree Self-Pay Contribution as required under the Plan.
28
25-Year Combined Service Rule C-Card & F-Card Service
Generally, Credited Service is only earned under Pension Plan 2 (formerly Pension Plan 4) by Communication Participants
between 1995 & 1996 and is based on 400 - 1,800 Contributed Hours per calendar year.
For Building, Hotel, Sign and Maintenance Participants, Credited Service may be earned under Pension Plan 2 (formerly
Pension Plan 4) beginning January 1978 and is based on a 400 – 1,800 Contributed Hours per calendar year.
Contact the Fund Oce for further information.
The 30-Year Rule
You are eligible for Retiree Health Benefits under the 30-Year Rule if you meet all the following criteria:
• You are receiving a retirement benefit from and have a combined total of at least 30 years of (i) Credited Service
under Pension Plan No. 2; and/or (ii) eligibility service earned under Pension Plan No. 2 solely from employment
as a Union business representative, Apprentice School teacher or Apprentice School administrator; and
• You continuously pay the applicable Retiree Self-Pay Contribution as required under the Plan.
If you do not satisfy the requirements for Retiree Health Benefits before your Retirement Date and you commence
your Pension Plan 2 benefits, you will not be able to return to work and qualify. Additional credit earned after your
Retirement Date will not aect your eligibility for Retiree Health Benefits. Your initial Retirement Date will always be
used for determining your eligibility for Retiree Health Benefits.
5.02 Dependent Eligibility
If you are eligible for Retiree Health Benefits, you may enroll any individual that qualifies as your Dependent as of your
Retirement Date. You may not add any individual that first qualifies as a Dependent after your Retirement Date.
5.03 Retiree Interim Coverage
If you stop working at age 60, elect COBRA coverage for 18 months and meet the eligibility requirements for Retiree
Health Benefits listed above (except for the age requirement), you may request Retiree Interim Coverage under the
Plan for up to six (6) additional months. The payment and monthly cost of Retiree Interim Coverage is the same as the
monthly cost of COBRA coverage, and you must pay the full cost of coverage. Retiree Interim Coverage is intended
to provide you with continuous coverage under the Plan until you reach age 62, at which time you would be eligible
for Retiree Health Benefits under the Plan. You MUST contact the Fund Office to request Retiree Interim Coverage
before the expiration of your COBRA coverage. It is your responsibility to request, in writing, Retiree Interim
Coverage. Receiving Retiree Interim Coverage is no guarantee that you are eligible for Retiree Health Benefits.
For Example – Retiree Interim Coverage: Your birthday is March 15, 1965. You stop working and lose coverage as of
March 31, 2025 at the age of 60. You elect COBRA coverage for the maximum period (18 months), so you have COBRA
coverage from April 1, 2025 through September 30, 2026. As of September 30, 2026, you are age 61. Assume you meet
the service requirements for Retiree Health Benefits. You request in writing to the Fund Oce to receive Retiree Interim
Coverage for up to six (6) additional months, from October 1, 2026 through March 31, 2027. When the Retiree Interim
Coverage ends as of March 31, 2027, you retire at age 62 and can begin Retiree Health Benefits (since this example
assumes you met the service requirement for Retiree Health Benefits).
SUMMARY PLAN
DESCRIPTION
29
5.04 Retiree Self-Pay Contributions
A Retiree Self-Pay Contribution is required to maintain your eligibility for Retiree Health Benefits. The monthly Retiree
Self-Pay Contribution applies to you and each of your eligible Dependents. The Retiree Self-Pay Contribution does not
apply to (1) surviving spouses or (2) if your birth date is on or before January 1, 1938.
Amount of Retiree Self-Pay Contribution
The amount of the required Retiree Self-Pay Contribution is determined by the Board of Trustees and may be subject
to change prospectively from time to time. The current Retiree Self-Pay Contribution amount is $100 per covered
person, per month.
However, if you retire with a 60 and Out Pension, the Retiree Self-Pay Contribution amount for you and your eligible
Dependents is $200 per covered person per month. Once you reach age 62, your Retiree Self-Pay Contribution will
be reduced to $100 per person, per month.
The amount of the monthly Retiree Self-Pay Contribution for you and your eligible Dependents will decrease by fifty
percent (50%) starting with the month following your 80th birthday.
When Deductions Begin
If you are determined to have met the qualifications for Retiree Health Benefits at the time you Retire, your Retiree
Self-Pay Contribution will begin as follows:
• Early Retirement: At age 62.
• Normal Retirement & 60 and Out Retirement: The later of your Retirement Date or the first of the month
following the date your Active Employee coverage runs out.
• Disability Retirement: Retroactive to the first day of the month coinciding with or next following the date your
Notice of Award for Social Security Disability Insurance (SSDI) was issued.
Important Note: Coverage based on non-contributory hours will not be used to extend active coverage post-
retirement and will not defer your Retiree Self-Pay Contributions, unless it is a result of an Employee paid Self-Pay
(see Section 3.02) to continue your Active Employee coverage.
Automatic Deduction of Retiree Self-Pay Contribution
The amount of the required Retiree Self-Pay Contribution for you and your eligible Dependent(s) is automatically
deducted from the monthly pension benefit payment, provided you authorize such automatic deduction in writing on
a form provided by the Fund Oce. This authorization is continuing and for an indefinite duration until and unless the
Fund Oce receives your revocation of such authorization.
If the amount of your Retiree Self-Pay Contribution for you and your eligible Dependent(s) exceeds your monthly
pension benefit payment, then the amount of your required Retiree Self-Pay Contribution for you and your eligible
Dependent(s) is deemed to be the amount of your monthly pension benefit.
If you do not contribute the required monthly Retiree Self-Pay Contribution for you and your eligible Dependent(s)
(e.g., if you have not authorized the deduction from your monthly pension benefit payment), Retiree Health Benefits
for you and your eligible Dependent(s) will be suspended until payment is received. Once the Fund Oce receives
payment of all outstanding monthly Retiree Self-Pay Contributions, Retiree Health Benefits for you and your eligible
Dependent(s) will be retroactively reinstated.
30
5.05 Retiree Benefit Opt-Out
If you and/or your Dependents are covered under another group health plan, you may armatively elect to opt-out
of Retiree Health Benefits under the Plan by submitting the necessary documentation, including a copy of insurance
card for the other coverage, to the Fund Oce. Your Dependent will also be required to complete a form indicating
that he or she understands that he or she will no longer have coverage under the Plan and because this is not a
Qualifying Event, will not be eligible for COBRA coverage. This form must be notarized. If you or your Dependent
choose to opt-out of Retiree Health Benefits, coverage under the Plan will terminate and you or your Dependent
will not be allowed to opt back into the Plan at any later date, except as provided below.
You and/or your eligible Dependents may opt back into the Plan at a later date provided the following conditions
are met:
• There is no gap in coverage between the other group health plan and the Plan (a Certificate of Creditable
Coverage or other proof of prior coverage is required);
• The other group health plan coverage is lost by reason of termination of employment, termination of the plan,
death or divorce (not including failure to pay premiums or otherwise opting out of coverage); and
• The application to opt back into the Plan is made within 60 days of the termination of the other group health
plan coverage.
5.06 When Retiree Health Benefits End
Retiree Health Benefits under the Plan are not vested and will not vest at any time. Accordingly, your coverage for
Retiree Health Benefits ends when the first of the following occurs:
• You fail to meet the eligibility requirements for Retiree Health Benefits;
• You die;
• The Board of Trustees discontinues Retiree Benefits under the Plan for any reason; or
• The Board of Trustees terminates the Plan for any reason.
SUMMARY PLAN
DESCRIPTION
31
SECTION 6: CONTINUATION OF HEALTH
COVERAGE UNDER COBRA
6.01 COBRA Coverage at a Glance
The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”), requires that participants
and their eligible Dependents have an opportunity to continue certain coverage for benefits under the Plan when they
would otherwise lose coverage under the Plan due to a Qualifying Event.
6.02 Eligibility for COBRA Coverage
After a Qualifying Event, COBRA coverage must be oered to each person who is a “qualified beneficiary.” Qualified
beneficiaries include you, your spouse, and your Dependent Children who were covered by the Plan on the day before
the Qualifying Event.
If you have a newborn child, adopt a child or have a child placed with you for adoption (for whom you have financial
responsibility) while you are covered under COBRA, you may add the child to your COBRA coverage immediately.
Your new child is considered a “qualified beneficiary.”
A child born to, adopted by or placed for adoption with you during the period of COBRA coverage would also be a
qualified beneficiary with a right to COBRA coverage. Each qualified beneficiary has an independent right to elect
COBRA coverage. If you have any questions about your eligibility for COBRA, please contact the Fund Oce.
6.03 Types of COBRA Coverage
The Plan provides two (2) options for COBRA coverage for you and your covered Dependents (or former Dependents):
(1) medical, prescription drug, dental, orthodontic, and vision coverage; or (2) medical and prescription drug
coverage only. You receive the same benefits available to Active Employees for the option you choose.
COBRA does not extend to other benefits under the Plan, such as Short-Term Disability, Long-Term Disability,
Maternity Leave Benefits, Life Insurance or AD&D.
6.04 Qualifying Events
Qualifying Events are certain circumstances that cause you and/or your covered Dependents to lose coverage under
the Plan.
If you are an Active Employee, COBRA coverage for you and your covered Dependents continues for up to 18 months
if you become eligible for COBRA because your hours are reduced below the number required for coverage or your
employment is terminated for any reason (other than gross misconduct).
The following constitute Qualifying Events for your eligible Dependents enabling them to enroll in COBRA coverage for
up to 36 months:
• Your death;
• Failure to meet the definition of “Dependent” under the terms of the Plan;
• Your divorce or legal separation; or
• You become entitled to Medicare.
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6.05 Duration of COBRA Coverage
COBRA coverage can continue for up to 18, 29 or 36 months depending on the Qualifying Event. If more than
one Qualifying Event applies, the maximum coverage period is 36 months total. The following chart shows when
you and your Dependents may qualify for continued coverage under COBRA and how long your COBRA coverage
may continue.
Maximum Period Coverage Can Continue
COBRA Qualifying Event You Spouse Dependent Child
You lose coverage because:
• Your hours are reduced
• Your employment ends for any reason
(except gross misconduct)
18 months 18 months 18 months
You or your qualified Dependent are
disabled (as defined by Social Security)
when you lose coverage or within 60 days
of the date you lose coverage
29 months 29 months 29 months
You die N/A 36 months 36 months
You and your spouse divorce or become
legally separated
N/A 36 months 36 months*
You become entitled to Medicare** N/A 36 months 36 months
Your Child no longer qualifies as an
eligible Dependent under the Plan
N/A N/A 36 months
* Only if the dependent child loses coverage as a result of divorce or legal separation (i.e., stepchildren).
** If you become entitled to Medicare before your coverage ends, your spouse and any Dependent Children are
entitled to elect COBRA coverage for up to the greater of 36 months from the date of Medicare entitlement, or 18
months from the date your coverage ends.
Extended COBRA Period for Disability
The 18-month COBRA coverage period may be extended by up to 11 months for a total of 29 months if a qualified
beneficiary is determined by the Social Security Administration to be disabled at any time within 60 days of the start
of the COBRA period. This 11-month extension is available to all COBRA qualified beneficiaries in your family. To be
granted this extension, you must notify the Fund Oce in writing within 60 days of the disability determination by the
Social Security Administration and within the 18-month COBRA coverage period. You must also provide a copy of the
determination of disability notification from the Social Security Administration.
The disabled individual must also notify the Fund Oce within 30 days of any final determination that such individual
is no longer disabled.
SUMMARY PLAN
DESCRIPTION
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Multiple Qualifying Events
The 18-month COBRA period may be extended for up to a maximum of 36 months for your spouse and Dependent
children who are qualified beneficiaries if a second Qualifying Event (death, divorce, legal separation or a Dependent
child ceasing to be a Dependent under the terms of the Plan) occurs during the 18-month COBRA coverage period.
However, this extension will only be allowed if the second event would have caused the spouse or Dependent child
to lose coverage under the Plan had the first Qualifying Event not occurred. To be granted an extension, the qualified
beneficiary must notify the Fund Oce within 60 days of the second Qualifying Event.
Please note your Medicare entitlement (Part A, Part B or both) is considered a second Qualifying Event for your
spouse and Dependent children under the Plan.
6.06 Cost of COBRA Coverage
You are responsible for the cost of COBRA coverage. When you and/or your Dependents become eligible for this
coverage, the Fund Oce will notify you of the COBRA premium amount.
Your COBRA premium may be as much as 102% of the regular contribution rate or the cost of coverage for
Participants and Dependents (100% of the premium plus a 2% administration fee). If you are eligible for the 11-month
extension due to a determination of disability by the Social Security Administration, your COBRA payment may be as
high as 150% of the Plan’s cost for the additional 11 months. The COBRA premiums are determined by the Board of
Trustees and adjusted from time to time.
6.07 Payment for COBRA Coverage
You and/or your Dependents who are electing COBRA coverage must make the initial payment for coverage no later
than 45 days after the date of your election for COBRA coverage. You are responsible for making sure that the amount
of your first payment is enough to cover the entire period, and you may contact the Fund Oce to confirm the correct
amount of your first payment. Any claims filed will not be paid until the Plan receives your payment.
After your initial premium payment, payments are due monthly and must be continuous. The due date for each
following monthly payment is the first day of the month for which payment is due. Payment will be considered on time
if it is received within 30 days of the due date. If you do not make a timely payment, your COBRA coverage will end,
and it cannot be reinstated.
6.08 Notification Responsibilities
Your employer is required to notify the Fund Oce of your death, termination of employment, reduction in hours or
Medicare entitlement within 30 days after such event occurs. However, because your employer may not be aware of
these events, you or your Dependents should notify the Fund Oce of any Qualifying Event as soon as it occurs.
For other Qualifying Events (your divorce or legal separation, or ineligibility of a Dependent Child), you or your
Dependent must notify the Fund Oce within 60 days of the date coverage terminates. If you do not provide the
notice to the Fund Oce within 60 days of the loss of coverage, the Dependent will not be eligible for COBRA
coverage.
When the Fund Oce is notified of a Qualifying Event, the Fund Oce will send a COBRA election notice and COBRA
election form to you and any Dependents who would lose coverage due to the Qualifying Event. The Fund Oce will
send the notice within 14 days of the time it receives notice of a Qualifying Event. The election notice tells you about
your right to elect COBRA coverage, the due dates for returning the election form, the cost of COBRA coverage and
the deadlines for payments.
To protect your family’s rights, you should notify the Fund Oce of any changes in your address or the addresses of
your Dependents.
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6.09 Electing COBRA Coverage
COBRA coverage is administered by the Fund Oce. If you are eligible for COBRA coverage, you will receive an
election form from the Fund Oce. You and your Dependents must complete the election form and send it back to
the Fund Oce to elect COBRA coverage. The following rules apply to the election of COBRA coverage:
• Each qualified beneficiary has a separate right to elect COBRA coverage. For example, your spouse may elect
COBRA coverage even if you do not.
• You may elect COBRA coverage on behalf of your spouse, and parents may elect COBRA coverage on behalf of
their Dependent Children. However, your Dependents have the right to revoke that election before the end of the
election period.
• If you do not elect COBRA coverage for your Dependents when they are entitled to COBRA coverage, your
Dependents have an independent right to elect COBRA coverage for themselves.
• You or your aected Dependent must elect COBRA coverage within 60 days after the Fund Oce mails your
election form or 60 days after your coverage would terminate, whichever is later. An election of COBRA coverage
is considered to be made on the date the COBRA election form is postmarked.
• If you do not elect COBRA coverage within the 60-day period described above, you and/or your Dependents will
be considered to have waived your rights to COBRA coverage.
6.10 Termination of COBRA Coverage
COBRA coverage may terminate before the end of the maximum coverage period for any of the following reasons:
• Any required premiums are not paid in full by the due date.
• A qualified beneficiary becomes covered under another group health plan after electing COBRA coverage.
• A qualified beneficiary becomes eligible for Medicare after electing COBRA coverage (this only aects the person
with Medicare coverage).
• A qualified beneficiary recovers from a disability during the 11-month extension period.
• The Plan ceases to provide group health coverage to any individual.
COBRA coverage may also be terminated for any reason the Plan would terminate coverage for a participant not
receiving COBRA coverage (such as gross misconduct). If your COBRA coverage terminates for any reason,
it cannot be reinstated.
6.11 Health Coverage Alternatives
You and your Dependents may be eligible for coverage through the Health Insurance Marketplace. In the
Marketplace, you could be eligible for a tax credit that lowers your monthly premiums, and you can see what your
premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA
coverage does not limit your eligibility for coverage for a tax credit through the Health Insurance Marketplace.
Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you
are otherwise eligible (such as a plan sponsored by your spouse’s employer), even if the plan generally does not
accept late enrollees, if you request enrollment within 30 days. You should review your options under the Health
Insurance Marketplace and other possible group health plans and compare them with the Plan’s COBRA coverage
to determine which option is best for you and your family. If you have any questions about your rights to COBRA
coverage, you should contact the Fund Oce. For information on the Health Insurance Marketplace, please visit
www.healthcare.gov.
SUMMARY PLAN
DESCRIPTION
35
SECTION 7: MEDICAL BENEFITS
The Plan provides you and your eligible Dependents medical benefits to help you pay for covered Medical Care and
protect you from the financial impact of catastrophic expenses.
7.01 Calendar Year Deductible
The Deductible is the amount of covered medical expenses that you and your eligible Dependents pay each calendar
year before the Plan begins to pay benefits. The amounts of the individual and the family Deductibles are listed in the
Schedule of Benefits at the front of this booklet.
The family Deductible may be satisfied through any combination of individual Deductibles. Once you meet the family
Deductible, no further Deductible will be applied to any eligible member of your family during the remainder of the
calendar year.
Identification (I.D.) Cards
If you’ve lost or misplaced your I.D. card, contact Blue Cross Blue Shield of Illinois at 1-800-862-3386 for a replacement
I.D. card or you may call the Fund Oce.
7.02 Copayments and Coinsurance
Once you satisfy the calendar year Deductible, the Plan will pay, up to any Plan maximums, the percentage of your
covered medical expenses listed in the Schedule of Benefits up to the Eligible Charge.
Any Copayments and Coinsurance payments made by you will count towards your annual medical out-of-pocket
maximum.
7.03 Out-of-Pocket Maximum
The Plan limits the amount you must pay for covered medical expenses in any calendar year. These out-of-pocket
maximums are listed in the Schedule of Benefits. Once you reach the applicable out-of-pocket maximum, which
diers depending on whether the provider is Network or Non-Network, the Plan pays 100% of all additional covered
medical expenses, up to any specific Plan maximums, for the remainder of the calendar year.
The family out-of-pocket maximum may be satisfied through any combination of individual out-of-pocket maximums.
Once you meet the family out-of-pocket maximum, no further individual out of-pocket maximum will be applied to any
eligible member of your family during the remainder of the calendar year.
The amounts excluded from the out-of-pocket maximums are provided in the Schedule of Benefits.
7.04 Preferred Provider Organization (PPO)
General Information
The Fund has contracted with a preferred provider organization (PPO) to help control medical costs. A PPO is a
medical organization that allows you to choose from a list of participating providers. The providers agree to provide
services at discounted fees that are generally lower as a result of the Plan’s participation in the PPO.
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To minimize your out-of-pocket costs, contact Blue Cross Blue Shield of Illinois, the Claims Administrator, for
information about which Hospitals and providers are in the Plan’s Network. You are not required to use Network
Providers and Hospitals, but when you use Network Providers and Hospitals rather than Non-Network Providers and
Hospitals, you can generally reduce costs for both you and the Plan.
If your Network Provider refers you to a specialist, the referral is typically to another Network Provider. However, it
is your responsibility to confirm that the specialist is a Network Provider.
For a directory of Network Providers, visit www.bcbsil.com or call BCBS at 1-800-810-2583. You may also contact
your Physician directly to confirm whether he or she participates in the BCBS PPO network.
Continuing Care
If you are a continuing care patient, and the contract with your Network provider or facility terminates, or the Plan
changed benefits because the provider or facility left the Network, then you may qualify for transitional care from the
Provider or facility for up to ninety (90) days at Network cost sharing. You are a “continuing care patient” if you are
receiving treatment for a serious and complex condition, are undergoing a course of institutional or inpatient care,
are scheduled for non-elective surgery, are pregnant and undergoing a course of treatment for pregnancy or are
determined to be terminally ill and receiving treatment for such illness. This provision does not apply to contracts with
Network Providers or facilities that terminate for-cause (provider fails to meet quality standards or commits fraud).
You will be notified by the Claims Administrator if this provision may apply to you.
7.05 Non-Network Benefits
Because Non-Network Providers have not agreed to accept discounted and negotiated rates, they may charge any
amount for services or supplies – which can cost you more. This means that if you use a Non-Network Provider, you
may have larger out-of-pocket expenses, a lower percentage paid by the Fund, and the Non-Network Provider may
charge you the dierence between the Eligible Charge and the total billed amount, a practice known as Balance
Billing for which you are responsible. To determine the Eligible Charge for a Non-Network Provider, the Plan uses
Usual and Customary Rates (“U&C”) or 100% of the current Medicare Reimbursement Rate, as indicated in the
Schedule of Benefits.
Charges by Non-Network Providers above the Eligible Charge do not count toward the Deductible or out-of-pocket
maximum. Additionally, if you use a Non-Network Provider, you may have to pay the Non-Network Provider first, file
claim forms and then wait for reimbursement from the Plan.
7.06 Out-of-Area Benefits
If there are no Network Providers within 10 miles of your home (as defined below), you may be eligible to receive
out-of-area benefits from the Plan. If you receive out-of-area benefits, any amount you pay above the Non-Network
charges does not apply to your Deductible or out- of-pocket maximum.
For purposes of out-of-area benefits, “home” means the address that the Fund Oce has on file for you at the time of
treatment.
7.07 Prior Authorization, Case Management and Utilization Review
For certain services, your provider will need to verify treatment and services prior to those treatments and services
being performed. Failure to request prior approval of benefits may result in treatment and service being denied after
they have already been performed. If services aren’t approved ahead of time, you may be responsible for charges.
SUMMARY PLAN
DESCRIPTION
37
Prior-Authorization
Prior Authorization is the process of obtaining approval from the Plan before you have certain procedures performed.
For Inpatient Hospital facility services, your Participating Provider is required to obtain Prior Authorization. If Prior
Authorization is not obtained, the Participating Provider will be sanctioned based on Blue Cross Blue Shield’s
contractual agreement with the Provider, and you will be held harmless for the Provider sanction.
If you fail to contact the Claims Administrator or to comply with the determinations of the Claims Administrator, as
described in this section, then your benefits may be reduced. These reductions in benefits are in addition to the
applicable Copayments, Coinsurance, Deductibles, and out-of-pocket expense limit amounts. Providers may bill you
for any reduction in payment, as described in this section, resulting from the failure to contact Blue Cross Blue Shield
or to comply with the determinations of Blue Cross Blue Shield. We encourage you to call ahead to verify if prior
authorization is necessary. The prior-authorization toll-free telephone number is on the back of your Identification
Card.
To receive maximum benefits under the Plan, you must obtain Prior Authorization from the Claims Administrator
before you receive treatment or are admitted for the following types of services. Providers may obtain Prior
Authorization for you, by contacting the Claims Administrator when required, however, it is your responsibility to
ensure Prior Authorization requirements are satisfied.
• Pre-admission Review
– Non-Emergency/Non-Maternity Inpatient Hospital – at least one (1) day prior to admission.
– Emergency – no later than two (2) business days or as soon as reasonably possible after the admission has
occurred.
– Pregnancy/Maternity – no later than two (2) business days after the admission has occurred. Even though
you are not required to call the Claims Administrator prior to your maternity admission, if you call the medical
pre-authorization number as soon as you find out you are pregnant, the Claims Administrator will provide you
with information on support programs to assist you during pregnancy.
– Skilled Nursing Facility – no later than one (1) business day prior to the scheduling of the admission.
– Coordinated Home Care Program – at least one (1) day prior to admission.
– Private Duty Nursing Service – at least one (1) day prior to receiving services.
– Certain Outpatient Procedures, including but not limited to private duty nursing, transplant evaluations
and hospice care. You or someone on your behalf must notify the Claims Administrator no later than two (2)
business days prior to receiving these services.
– Durable Medical Equipment.
– Length of Stay/Service – upon completion of the Inpatient or emergency admission review, the Claim
Administrator will send a letter to you, your Physician, Provider of services, behavioral health practitioner and/
or the Hospital or facility with a determination on the approved length of stay.
An extension of the length of stay/service will be based solely on whether continued Inpatient care or other
health care service is Medically Necessary. If the extension is determined not to be Medically Necessary, the
authorization will not be extended. Additional notification will be provided to your Physician and/or the Hospital
regarding the denial of payment for the extension.
A length of stay/service review, also known as a concurrent Medical Necessity review, is when you, your
Provider, or other authorized representative may submit a request to the Plan for continued services. If you,
38
your Provider, or authorized representative requests to extend care beyond the approved time limit and it is
a request involving urgent care or an ongoing course of treatment, the Plan will make a determination on the
request/appeal as soon as possible but no later than 72 hours after it receives the initial request, or within 48
hours after it receives the missing information (if the initial request is incomplete).
• Behavioral Health
– Inpatient Hospital – at least one (1) day prior to admission.
– Emergency Mental Health or Substance Use Disorder – no later than two (2) business days or as soon as
reasonably possible after the admission has occurred.
– Residential Treatment Center – at least one (1) day prior to scheduling admission.
– Partial Hospitalization Treatment Program – no later than 48 hours after the admission for the treatment of
mental illness or substance use disorder.
Please remember that prior authorization does not verify eligibility for benefits or guarantee benefit payments under
the Plan. Prior authorization also does not constitute a guarantee or warranty of the quality of treatment you
receive.
For Non-Network Providers Only: If you fail to obtain prior authorization, all Eligible Charges incurred may be subject
to an additional $200 penalty before any payment is made by the Plan. If assessed, the penalty does not apply
toward your out-of-pocket maximum. Additionally, room and board expenses may be covered at 50% of the Eligible
Charge for not pre-certifying a Hospital admission and for any admission reviewed but not approved.
Case Management and Utilization Review
Case management is a collaborative process that assists you with the coordination of complex care services. A Blue
Cross Blue Shield case manager is available to you, at no cost, as an advocate for cost-eective interventions. Case
managers are also available to provide assistance when you need alternative benefits. Alternative benefits will be
provided only so long as Blue Cross Blue Shield determines that the alternative services are Medically Necessary and
cost-eective. The total maximum payment for alternative services shall not exceed the total benefits for which you
would otherwise be entitled under the Plan.
Provision of alternative benefits in one instance shall not result in an obligation to provide the same or similar benefits
in any other instance. In addition, the provision of alternative benefits shall not be construed as a waiver of any of the
terms, conditions, limitations, and exclusions of the Plan.
Blue Distinction® and Blue Distinction Specialty Care Program
Blue Distinction® (“Blue Distinction”) is a national designation awarded by Blue Cross and Blue Shield Plans to health
care Providers. The Blue Distinction Specialty Care program includes two levels of designation: Blue Distinction
Centers (BDC) and Blue Distinction Centers+ (BDC+). The Blue Distinction Specialty Care program focuses on BDC
and BDC+ providers.
Blue Distinction Centers
The Blue Distinction designation uses nationally consistent criteria to designate high-performing providers based on
objective, evidence-based selection criteria. The Blue Distinction Specialty Care program’s purpose is to assist you
in finding BDC and BDC+ providers that have met overall quality measures for patient safety and outcomes, fewer
medical complications, lower readmission rates, and higher survival rates in the administration of specialty care. Blue
Distinction Centers provide care in the following specialty care areas:
• Cardiac care
SUMMARY PLAN
DESCRIPTION
39
• Cellular immunotherapy (CAR-T)
• Substance use treatment and recovery
• Spine Surgery
• Bariatric Surgery
• Knee and hip replacement Surgery
• Maternity care
• Transplants
While you are free to choose to receive treatment at a non-BDC and/or non-BDC+ provider; you may notice higher
costs for services or that you may be balance billed since many are out-of-network.
For additional information regarding Blue Distinction Centers for specialty care, please contact a Customer Service
Representative at the toll-free telephone number shown on your Identification Card or visit the following website:
https://www.bcbsil.com/find-care/blue-distinction-specialty-care/blue-distinction.
7.08 No Surprises Act
To the extent required by law, the Plan will comply with the No Surprises Act and the regulations promulgated
thereunder. The No Surprises Act generally protects you from “balance billing” for Non-Network Emergency
Services, Non-Network air ambulance services, and certain non-emergency services performed by a Non-Network
Provider or facility.
Emergency Services
If you have an Emergency Medical Condition and receive Emergency Services from a Non-Network Provider or
facility, the most the Provider or facility may bill you is the Plan’s Network cost-sharing amount (such as copayments
and coinsurance). You cannot be balance billed for these Emergency Services. This includes services you may get
after you are in stable condition, unless you provide written consent and give up your protection not to be balanced
billed for these post-stabilization services. Note that this does not apply to ground ambulance services.
Non-Emergency Services from a Non-Network Provider at a Network Facility
If you receive services from a Network Hospital or ambulatory surgical center, certain providers may be considered
Non-Network providers. Under the No Surprises Act, the most these providers may bill you is the Plan’s Network
cost-sharing amount (such as copayments and coinsurance). This applies to emergency medicine, anesthesia,
pathology, laboratory, neonatology, assistant surgeon, hospitalist or intensivists services. These providers cannot
balance bill you and may not ask you to give up your protection not to be balance billed.
If you receive other services at these Network facilities, the Non-Network providers cannot balance bill you, unless
you provide written consent and give up your protections. You are never required to give up your protections from
balance billing.
Non-Network Air Ambulance Services
If you receive air ambulance services from a Non-Network provider, the most the provider may bill you is Plan’s
Network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these
services.
Complaint Process
If you believe you have been wrongly billed or otherwise have a complaint under the No Surprises Act, you may
contact the Fund Oce, or the No Surprises Help Desk at 1-800-985-3059.
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7.09 Covered Medical Expenses
The Plan covers the Eligible Charge for the following services and supplies provided or ordered by a Physician (except
as specifically provided otherwise) that you receive for the treatment of a non-occupational accident or sickness
when Medically Necessary, subject to the Plan maximums and limitations provided in the Schedule of Benefits.
Hospital Covered Services
Inpatient Hospital Care
The following are Covered Services when you receive them as an Inpatient in a Hospital:
• Inpatient Covered Services
– Bed, board and general nursing care when you are in: (a) a semi-private room; (b) a private room; or (c) an
intensive care unit.
– Ancillary services (such as operating rooms, drugs, surgical dressings and lab work).
• Preadmission Testing
Benefits are provided for preoperative tests given to you as an Outpatient to prepare you for Surgery which you
are scheduled to have as an Inpatient, provided that benefits would have been available to you had you received
these tests as an Inpatient in a Hospital. Benefits will not be provided if you cancel or postpone the Surgery.
These tests are considered part of your Inpatient Hospital surgical stay.
• Partial Hospitalization Treatment
Benefits are available for this program only if it is an Administrator Program. No benefits will be provided for
services rendered in a Partial Hospitalization Treatment Program which has not been approved by the Claims
Administrator.
• Coordinated Home Care
Benefits will be provided for services under a Coordinated Home Care Program. There is no limit on visits under
the Coordinated Home Care Program per calendar year.
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any
Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a
vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally does not prohibit
the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law,
require that a provider obtain authorization from the Plan or the insurance issuer for prescribing a length of stay not
more than 48 hours (or 96 hours as applicable).
Outpatient Hospital Care
The following are Covered Services when you receive them from a Hospital as an Outpatient:
• Surgery and any related Diagnostic Service received on the same day as the Surgery
• Radiation therapy treatments
• Chemotherapy
• Electroconvulsive therapy
• Renal dialysis treatments – if received in a Hospital, a dialysis facility, or in your home under the supervision of a
Hospital or dialysis facility
SUMMARY PLAN
DESCRIPTION
41
• Diagnostic services – when you are an Outpatient, and these services are related to Surgery or medical care
• Emergency accident care
• Emergency Services
• Bone mass measurement and osteoporosis – benefits will be provided for bone mass measurement and the
diagnosis and treatment of osteoporosis
Hospice Care Program
Your Hospital coverage also includes benefits for Hospice Care Program Service. Benefits will be provided for the
Hospice Care Program Service described below when these services are rendered to you by a Hospice Care Program
Provider.
However, for benefits to be available, you must have a terminal illness with a life expectancy of six (6) months or less,
as certified by your attending Physician, and you will no longer benefit from standard medical care or have chosen
to receive hospice care rather than standard care. Also, a family member or friend should be available to provide
custodial type care between visits from Hospice Care Program Providers if hospice is provided in the home.
The following services are covered under the Hospice Care Program:
• Coordinated Home Care
• Medical supplies and dressings
• Medication
• Nursing Services - skilled and non-skilled
• Occupational therapy
• Pain management services
• Physical therapy
• Physician visits
• Social and spiritual services
• Respite care service
Physician Covered Services
• A1C Testing for prediabetes, type I diabetes, and type II diabetes mellitus.
• Allergy Injections and Allergy Testing.
• Amino Acid-Based Elemental Formulas for the diagnosis and treatment of eosinophilic disorders or short-
bowel syndrome, when the prescribing Physician has issued a written order stating that the amino acid-based
elemental formula is Medically Necessary.
• Autism Spectrum Disorder treatment shall include the following care when prescribed or ordered by an individual
with an Autism Spectrum Disorder: (a) by a Physician or Psychologist who has determined that such care is
Medically Necessary; or (b) by a certified, registered, or licensed health care professional with expertise in
treating Autism Spectrum Disorders, including but not limited to, a health care professional who is eligible as
a Qualified ABA Provider by state regulation and when such care is determined to be Medically Necessary and
ordered by a Physician or Psychologist:
– Psychiatric care, including diagnosis services
– Psychological assessments and treatments
– Habilitative or rehabilitative treatments
42
– Therapeutic care, including behavioral Speech, Occupational and Physical Therapies that provide treatment in
the following areas:
⚬ Self-care and feeding
⚬ Pragmatic, receptive and expressive language
⚬ Cognitive functioning
⚬ Applied behavior analysis (ABA)
⚬ Intervention and modification
⚬ Motor planning
⚬ Sensory processing
• Biomarker Testing for the purpose of Medically Necessary diagnosis, treatment, appropriate management, or
ongoing monitoring of a disease or condition.
• Blood Glucose Monitors for Treatment of Diabetes for Medically Necessary blood glucose monitors (including
non-invasive monitors and monitors for the blind), if a Physician has provided a written order.
• Bone Mass Measurement and the diagnosis and treatment Osteoporosis.
• Clinical Breast Examinations when performed by a Physician, advanced practice nurse or a physician assistant
working under the direct supervision of a Physician.
• Chemotherapy.
• Chiropractic and Osteopathic Manipulation or adjustment of osseous or articular structures, commonly referred
to as chiropractic and osteopathic manipulation, when performed by a person licensed to perform such
procedures. Your benefits for chiropractic and osteopathic manipulation will be limited to a maximum of 30 visits
per person, per calendar year, unless additional visits are determined to be Medically Necessary.
• Comprehensive Cancer Testing for Medically Necessary comprehensive cancer testing, including, but not limited
to, whole-exome genome testing, whole-genome sequencing, RNA sequencing, tumor mutation burden, and
targeted cancer gene panels.
• Consultations coverage is included only if requested by your Physician and consist of another Physician’s
advice in the diagnosis or treatment of a condition which requires special skill or knowledge. Benefits are not
available for any consultation done because of Hospital regulations or by a Physician who also renders Surgery or
maternity service during the same admission.
• Diabetes Self-Management Training and Education for Outpatient self-management training, education and
medical nutrition therapy. Benefits will also be provided for education programs that allow you to maintain a
hemoglobin A1c level within the ranges identified in nationally recognized standards of care. Benefits will be
provided if these services are rendered by a Physician, or duly certified, registered or licensed health care
professional with expertise in diabetes management, operating within the scope of his/her license. Benefits are
also available for regular foot care examinations by a Physician or Podiatrist.
• Diagnostic Services for those services related to covered Surgery or medical care.
• Durable Medical Equipment for such things as internal cardiac valves, internal pacemakers, mandibular
reconstruction devices (not used primarily to support dental prosthesis), bone screws, bolts, nails, plates and any
other internal and permanent devices. Benefits will also be provided for the rental (but not to exceed the total
cost of equipment) or purchase of durable medical equipment required for temporary therapeutic use provided
that this equipment is primarily and customarily used to serve a medical purpose.
SUMMARY PLAN
DESCRIPTION
43
• Emergency Services.
• Electroconvulsive Therapy.
• Fertility Treatment for Medically Necessary infertility treatment for Participants and their Dependent spouses.
Infertility means a disease, condition, or status characterized by the inability to conceive a child or to carry a
pregnancy to live birth after one (1) year of regular unprotected sexual intercourse or due to an impairment of
a person’s capacity to reproduce either as an individual or with her/his partner. However, earlier evaluation and
treatment may be justified based on medical history and physical findings and is warranted after 6 months for a
woman over 35 years of age (conceiving but having a miscarriage does not restart the 12 month or 6-month term
for determining infertility).
Infertility may be due to:
– Female factors (e.g. pelvic adhesions, ovarian dysfunction, endometriosis, prior tubal ligation, and absent or
nonfunctioning uterus);
– Male factors (e.g. abnormalities in sperm production, function, or transport, or prior vasectomy);
– A combination of both male and female factors; or
– Unknown causes.
If determined to be Medically Necessary, the covered infertility services included, but are not limited to, in-vitro
fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer,
zygote intrafallopian tube transfer, low tubal ovum transfer, intracytoplasmic sperm injection, oocyte and sperm
retrieval.
The Plan will not provide coverage for the following:
– Services or supplies rendered to a surrogate, except those costs for procedures to obtain eggs, sperm or
embryos from you will be covered if you choose to use a surrogate.
– Expenses incurred for cryo-preservation or storage of sperm, eggs, or embryos, except for those procedures
which use a cryo-preserved substance.
– Non-medical costs of an egg or sperm donor.
– Infertility treatments which are deemed experimental, investigational or unproven, in writing, by the American
Society for Reproductive Medicine or the American College of Obstetricians or Gynecologists.
– Expenses for services that, in the judgment of the Claims Administrator, are not Medically Necessary.
– Infertility treatment for Dependent Children.
Though this benefit does not require precertification, the Fund recommends you contact the Claims
Administrator prior to obtaining treatment to ensure it meets the guidelines for coverage.
• Hearing Examinations and Hearing Aids.
• Medical Care visits when:
– You are an Inpatient in a Hospital, a Skilled Nursing Facility, or substance use disorder treatment facility or a
Residential Treatment Center; or
– You are a patient in a Partial Hospitalization Treatment Program or Coordinated Home Care Program; or
– You visit your Physician’s oce, or your Physician comes to your home.
• Naprapathy.
• Occupational Therapy for occupational therapy when these services are rendered by a registered occupational
therapist under the supervision of a Physician. This therapy must be furnished under a written plan established
44
by a Physician and regularly reviewed by the therapist and Physician. The plan must be established before
treatment is begun and must relate to the type, amount, frequency and duration of therapy and indicate the
diagnosis and anticipated goals. Benefits for Outpatient Occupational Therapy will be limited to a maximum of
30 visits per person, per diagnosis, per calendar year, unless additional visits are determined to be Medically
Necessary. Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any occupational
therapy visit maximums indicated in the Schedule of Benefits section of this benefit booklet.
• Orthotic Devices for the body or a part of the body, head, neck or extremities, including but not limited to, leg,
back, arm and neck braces. In addition, benefits will be provided for adjustments, repairs or replacement of the
device because of a change in your physical condition, as Medically Necessary. Your benefits for foot orthotics
will be limited to two (2) foot orthotic devices or one pair of foot orthotic devices per calendar year.
• Outpatient Contraceptive Services for prescription contraceptive devices, injections, implants and outpatient
contraceptive services. Outpatient contraceptive services mean consultations, examinations, procedures and
medical services provided on an Outpatient basis and related to the use of contraceptive methods (including
natural family planning) to prevent an unintended pregnancy. Benefits for prescription contraceptive devices and
implants will not be subject to a calendar year maximum.
• Pancreatic Cancer Screening.
• Physical Therapy when rendered by a licensed professional physical therapist; provided, however, when the
therapy is beyond the scope of the physical therapist’s license, the physical therapist must be under the
supervision of a Physician, and the therapy must be furnished under a written plan established by a Physician
and regularly reviewed by the therapist and the Physician. The plan must be established before treatment is
begun and must relate to the type, amount, frequency and duration of therapy and indicate the diagnosis and
anticipated goals. Benefits for outpatient physical therapy will be limited to a maximum of 30 visits per person,
per diagnosis, per calendar year, unless additional visits are determined to be Medically Necessary. Benefits for
Autism Spectrum Disorder will not apply towards and are not subject to any physical therapy visits maximum
indicated in the Schedule of Benefits section of this benefit booklet.
• Prosthetic Appliances devices, special appliances and surgical implants when:
– They are required to replace all or part of an organ or tissue of the human body; or
– They are required to replace all or part of the function of a non-functioning or malfunctioning organ or tissue.
Benefits will also include adjustments, repair and replacements of covered prosthetic devices, special appliances
and surgical implants when required because of wear or change in a patient’s condition (excluding dental
appliances and replacement of cataract lenses when a prescription change is not required).
• Pulmonary Rehabilitation Therapy for outpatient cardiac/pulmonary rehabilitation programs provided within six
months of a cardiac incident and outpatient pulmonary rehabilitation services.
• Radiation Therapy Treatments.
• Routine Pediatric Hearing Examination.
• Speech Therapy when these services are rendered by a licensed speech therapist or speech therapist certified
by the American Speech and Hearing Association. Inpatient speech therapy benefits will be provided only if
speech therapy is not the only reason for admission. Outpatient speech therapy benefits will be limited to a
maximum of 30 visits per person, per diagnosis, per calendar year, unless determined to be Medically Necessary.
Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any speech therapy visits
maximum indicated in the Schedule of Benefits section of this benefit booklet.
• Surgery performed by a Physician, Dentist or podiatrist. However, for services performed by a Dentist or
SUMMARY PLAN
DESCRIPTION
45
podiatrist, benefits are limited to those surgical procedures which may be legally rendered by them, and
which would be payable to the Plan had they been performed by a Physician. Benefits for oral Surgery are
limited to the following services:
– Excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth;
– Surgical procedures to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor
of the mouth; and
– Excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation
for dentures or other prostheses); treatment of fractures of facial bone; external incision and drainage of
cellulitis; incision of accessory sinuses, salivary glands or ducts; reduction of dislocation of, or excision
of, the temporomandibular joints.
The following services are also part of your surgical benefits:
– Anesthesia Services – if administered at the same time as a covered surgical procedure in a Hospital
or surgical facility or by a Physician other than the operating surgeon or by a certified registered nurse
anesthetist. However, benefits will be provided for anesthesia services administered by oral and maxillofacial
surgeons when such services are rendered in the surgeon’s oce or ambulatory surgical facility.
In addition, benefits will be provided for anesthesia administered in connection with dental care treatment
rendered in a Hospital or ambulatory surgical facility if (a) a child is age 6 and under, (b) you have a chronic
disability, or (c) you have a medical condition requiring hospitalization or general anesthesia for dental care.
Benefits will be provided for anesthesia administered in connection with dental care treatment rendered in a
dental oce, oral surgeon’s oce, Hospital or ambulatory surgical facility if you are under age 19 and have
been diagnosed with an Autism Spectrum Disorder or a developmental disability.
– Assist at Surgery – when performed by a Physician, Dentist or podiatrist who assists the operating surgeon
in performing covered Surgery in a Hospital or ambulatory surgical facility. In addition, benefits will be
provided for assist at Surgery when performed by a Registered Surgical Assistant or an advanced practice
nurse. Benefits will also be provided for assist at Surgery performed by a physician assistant under the direct
supervision of a Physician, Dentist or podiatrist.
– Sterilization Procedures (even if they are voluntary rather than Medically Necessary).
• Vitamin D Testing in accordance with vitamin D deficiency risk factors identified by the United States Centers for
Disease Control and Prevention.
7.10 Other Covered Medical Expenses
• The processing, transporting, storing, handling and administration of blood and blood components.
• Ambulance Transportation – benefits will not be provided for long distance trips or for use of an ambulance
because it is more convenient than other transportation.
• Dental Accident Care – dental services rendered by a Dentist or Physician which are required as the result of an
accidental injury. The following services and supplies are covered only if needed because of accidental injury to
sound, natural teeth:
– Oral Surgery;
– Full or partial dentures;
– Fixed bridge work;
– Prompt repair to natural teeth; or
– Crowns.
46
A natural tooth is a virgin or unrestored tooth, or a tooth that has no decay, no filing on more than two surfaces,
no gum disease associated with bone loss, no root canal therapy, is not a dental implant and functions normally
in chewing and speech.
An accidental injury occurs when dental damage is severe enough that initial contact with a Physician or Dentist
occurred within 72 hours of the accident. Services must be provided and completed within six (6) months of an
injury and approved in advance by the Claims Administrator. Accidental injury coverage does not include damage
resulting from biting or chewing.
• Medical and surgical dressings, supplies, casts and splints.
• Medical and surgical benefits for mastectomies as required by federal law under the Women’s Health and Cancer
Rights Act of 1998 (“WHCRA”), including the following, when requested by the patient in consultation with her
Physician:
– Reconstruction of the breast on which the mastectomy has been performed;
– Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
– Prostheses and physical complications of all stages of mastectomy including lymphedemas.
• Oxygen and its administration.
• Preventive Services in accordance with federal law. The list of Preventive Services changes from time to time, so
please visit www.healthcare.gov/preventive-care-benefits for a comprehensive list.
• Charges for “routine patient costs” incurred by a “qualified individual” who is participating in an “approved
clinical trial.” For the purposes of this benefit, the following applies:
– A “qualified individual” is someone who is eligible to participate in an “approved clinical trial” and either the
individual’s doctor has concluded that participation is appropriate, or the Participant provides medical and
scientific information establishing that their participation is appropriate.
– “Routine patient costs” generally include all items and services that typically would be covered under the Plan
for an individual not enrolled in a clinical trial. Routine patient costs do not include the actual device, item or
service that is being studied. Also excluded are items and services that are given only to satisfy data collection
and analysis needs that are not used in the direct clinical management of the patient; or a service that is clearly
consistent with widely accepted and established standards or care for a particular diagnosis.
– An “approved clinical trial” means a Phase I, II, III, or IV clinical trial that studies the prevention, detection, or
treatment of cancer or other life-threatening conditions. The term life-threatening condition means any disease
or condition from which death is likely unless the disease or condition is treated.
• Treatment of Mental or Nervous Disorders.
• Treatment of Chemical Dependency/Substance Abuse.
• Treatment or Surgery for the occurrence of Morbid Obesity.
7.11 Medical Expenses not Covered by the Plan
The following is a list of procedures, services, supplies and types of treatment for which Plan benefits are not payable
or for which the benefits are limited as indicated below. The following list is not an all-inclusive or an exhaustive list;
rather, it is only representative of the types of services and supplies for which charges may be incurred but which are
not payable by the Plan.
Please keep in mind, the fact that your Physician may prescribe, order, recommend, approve or view hospitalization
or other health care services and supplies as medically necessary, does not make the hospitalization, services or
SUMMARY PLAN
DESCRIPTION
47
supplies medically necessary and does not mean that the Claims Administrator will pay the cost of the hospitalization,
services or supplies.
• Hospitalization, services and supplies which are not Medically Necessary.
• Expenses for services; supplies, treatments or procedures:
– which are not rendered for the treatment or correction of, or in connection with, a specific non-occupational
accident or sickness, unless specifically identified as being covered under the Plan. In excess of any maximum
benefit or limitation specified in the Plan;
– not specifically listed as a Covered Medical Expense under the Medical Benefit;
– Received by a person, facility or organization acting outside the scope of the applicable license;
– from more than one provider on the same day(s) to the extent benefits are duplicated;
– not provided in accord with generally accepted professional medical standards;
– that in the judgment of the Claims Administrator are not Medically Necessary; or
– For drug therapy programs not available in the United States or available in the United States only under
special license by the federal government for practitioners engaged in research.
• A pregnancy or pregnancy related conditions other than for a Participant or Dependent spouse, except as
required by the Aordable Care Act.
• Infertility related conditions other than for a Participant or Dependent spouse.
• Abortion procedures unless the life of the Participant or Dependent spouse is endangered or there is a medical
complication. For the avoidance of doubt, the Plan does not cover abortion procedures for a Dependent Child.
• Charges for marriage counseling and premarital exams.
• Any losses, expenses or charges for Cosmetic Surgical procedures and related expenses, except for the following:
– To correct the eects of an injury if the Surgery is performed in the year of the injury or the next year;
– To improve a congenital deformity; or
– To improve a deformity resulting from disease or Medically Necessary Surgery.
• Any type of rest cure or custodial care (care that is designed primarily to assist a person in meeting the activities
of daily living (e.g., milieu therapy)), regardless of what the care is called. This also includes, without limitation,
food, housing and supportive items such as air conditioners, handrails, ramps and telephones.
• Long term care services.
• Some Hospice related services, including not limited to:
– Durable Medical Equipment;
– Home delivered meals;
– Homemaker services;
– Traditional medical services provided for the direct care of the terminal illness, disease or condition; and
– Transportation, including, but not limited to, Ambulance Transportation.
• Inpatient private duty nursing services.
• Charges for psychological evaluations if they relate to fitness to act as a custodial parent or diagnosis of a learning
disability.
• Maintenance care.
48
• Habilitative services that are solely educational in nature or otherwise paid under state or federal law for purely
educational services.
• Broken appointments.
• Over-the-counter medications or baby formulas.
• Massage therapy.
• Weight loss programs.
• Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery implants, except as
specifically mentioned in the Plan.
• Dental braces and over-the-counter orthotics.
• Charges for services or supplies which constitute personal comfort or convenience items. Examples of items
that are not covered include, but are not limited to, the following: personal hygiene items, hair appointments,
magazines, cosmetics, guest trays, televisions, or telephone services.
• Dietary or nutritional counseling and supplements, except as required under federal law.
• Therapeutic devices and appliances, support garments or other non-medical items, regardless of their
intended use.
• Services or supplies which are not recognized as payable (in whole or in part) by Medicare, including services
and supplies that are more than the maximum number of such services/supplies allowed by Medicare where the
covered individual is eligible for Medicare.
• Expenses covered under the Plan’s Dental Benefit, Vision Benefit or Prescription Drug Benefit.
• Charges for any of the circumstances listed under the General Plan Limitations and Exclusions section of the Plan.
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49
SECTION 8: PRESCRIPTION DRUG BENEFITS
The Prescription Drug Benefit is administered by a prescription drug benefit manager (“PBM”) and is subject to the
contractual agreements between the Plan and PBM. The Prescription Drug Benefit includes a Network Pharmacy
Program, Mail Order or Maintenance Choice Program and Specialty Pharmacy Program to provide coverage for your
short-term and long-term prescription needs. Prescriptions purchased at a Non-Network Pharmacy are not covered
under the Plan.
8.01 Eligibility Requirements
The Prescription Drug Benefit applies to you and your Dependents if you are an Active Employee or Retiree, and you
are eligible for medical benefits under the Plan.
8.02 Formulary, Generic, Preferred and Non-Preferred Drugs
A drug formulary is a list of generic and brand-name prescription medications covered by the Plan. The Plan’s
formulary is divided into tiers based on the type of drug. If your prescription medication is included in a lower tier, it
will cost less. The formulary list is designed to help you get the medication you need at the lowest possible cost. While
it does not include every available medication, it includes options to treat most health conditions. If the prescription
medications you take are not included in the Plan’s formulary, you may be responsible for paying them out-of-pocket.
The amount of your prescription drug copayment will depend on whether the drug is generic, preferred or non-
preferred. The applicable copayments are listed in the Schedule of Benefits.
Generic drugs are chemically and therapeutically equivalent to their corresponding brand name counterpart.
Preferred drugs are typically brand name drugs which are included in the list of medications that are preferred by
the Plan and are determined by a committee of pharmacists and doctors to be the safest, most eective and most
economical.
Non-preferred drugs are not included in the preferred list of drugs and are generally more expensive, brand name
drugs. Drugs may change from preferred and non-preferred (and vice versa) from time to time.
For more information about which drugs are considered generic, preferred or non-preferred, please contact the PBM.
8.03 Out-of-Pocket Maximum
The maximum amount you pay for expenses under the Prescription Drug Benefit each calendar year is the out-of-
pocket maximum listed in the Schedule of Benefits. This is subject to change annually based on the federal out-
of-pocket-maximums. Once you reach the applicable out-of-pocket maximum, the Plan pays 100% of all covered
Prescription Drug Benefit expenses, up to any specific Plan maximums, for the remainder of the calendar year.
The family out-of-pocket maximum may be satisfied through any combination of individual out-of-pocket maximums.
Once you meet the family out-of-pocket maximum, no further individual out-of-pocket maximum will be applied to
any eligible member of your family during the remainder of the calendar year.
The out-of-pocket maximum for the Prescription Drug Benefit is separate from your out-of-pocket maximum for
the Medical Benefit, so your prescription drug copayments do not count towards your Deductible or out-of-pocket
maximum under the Medical Benefit and vice versa.
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8.04 Prior Authorization
Prior authorization (PA) is an extra layer of review that is needed for some medications. If your physician prescribes a
medication that is on the drug formulary and it is denied, prior authorization may be necessary. This process ensures
certain criteria is met before the Plan will cover your prescription. There are a few reasons why prior authorization
might be required. The medication may be unsafe when combined with other medications you are taking, used only
for certain health conditions, have the potential for misuse or abuse, or an eective alternative might be available. If
your medication does require a prior authorization, you should speak with your physician to determine if an alternative
is available. If not, then you or your pharmacist can ask your physician to start a prior authorization. The PBM will
then work with your physician to get additional information that will help them determine if the medication should be
covered. The process can take several days and depends on how complete and quickly information is provided and
reviewed. If approved, you can fill your prescription. If denied, you will receive a letter from the PBM and then you
can ask your physician if there is another medication covered by the Plan that may also work for you. You could also
choose to pay for the medication yourself at a Network Pharmacy, or you or your physician could submit an appeal
under the Plan.
8.05 Quantity Limits
A quantity limit is the highest amount of medication covered by the Plan for a period of time (e.g., 90 tablets per 90
days). The Plan will cover your medication up to the limit. Once the quantity limit is reached, you will have to pay the
full cost of the medication. Quantity limits are sometimes used to help make sure a medication is not overused or to
help save money for you and the Plan.
8.06 Mandatory Generic Drug Program
The Mandatory Generic Drug Program requires your pharmacist to fill your brand name prescriptions with a generic
equivalent whenever one is available, unless your Physician indicates that it is Medically Necessary for you to have
the brand name prescription. If your Physician indicates it is Medically Necessary for you to have the brand name
drug, you will be responsible for paying the appropriate brand name drug copay with no penalty. If your Physician
does not indicate it is Medically Necessary for you to have the brand name drug and you choose to purchase the
brand name drug when a generic equivalent is available, you will be responsible for the dierence in cost between
the generic drug and the brand name drug, plus the generic copayment.
8.07 Network Pharmacy Program
Important Note!
Always ask your pharmacy if it is a member of the CVS/Caremark network before filling a prescription. Prescriptions
purchased at a Non-Network pharmacy are not covered under the plan.
The Plan has contracted with CVS/Caremark and its network of pharmacies (“Network Pharmacies”) to fill
prescriptions for you and your covered Dependents. Before filling a prescription, ask the pharmacy if it is a member of
the CVS/Caremark network. Prescriptions purchased at a Non-Network Pharmacy are not covered under the Plan.
You must present your prescription drug identification card and pay the applicable copayment to receive benefits
for drugs bought at a pharmacy. For your covered Dependents’ prescriptions, you will also need to provide a date of
birth.
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FORGOT OR LOST YOUR PRESCRIPTION DRUG CARD?
You can access your CVS/Caremark ID card by downloading the CVS Caremark app on your mobile device by visiting
www.caremark.com and accessing your member portal.
If you do not present your prescription drug identification card when you visit a Network Pharmacy, you will be
reimbursed for any covered prescription drugs, provided you:
• Pay the full price of the prescription at the time of purchase;
• Have your pharmacist fill out a claim form; and
• Submit the claim form to the PBM for reimbursement.
Please be aware that your reimbursement may be less than if you had presented your prescription drug
identification card at the time of service. You will pay the copayment and any amounts above the Network
Pharmacy discount to the pharmacy.
8.08 CVS Mail Order and Maintenance Choice Program
If you take prescribed maintenance drugs (medications you fill each month for longer than 2 months), you have the
choice to receive up to a 90-day supply of your maintenance medication from a CVS/Caremark pharmacy or through
the CVS Mail Order Program.
The Plan allows you to obtain two (2) initial 30-day supply prescription fills of a maintenance medication from
a Network Pharmacy. After the two (2) initial fills, the Plan will cover your maintenance medications for 90-day
prescriptions and only if you have those medications are filled through either the CVS Mail Order Program or at a
CVS/Caremark pharmacy.
The first time you have a prescription filled through the CVS Mail Order Program, you will need to submit a copy of
your 90-day prescription, and the appropriate copayment along with an order form. New prescriptions generally take
2 to 3 days to process and fill. Refills take 1 to 2 days to process and fill. Shipping is free of charge and typically takes
10-14 days for standard delivery. You can choose 2-day or next-day shipping at an additional cost; however, it will still
take 1 to 3 days for your order to be processed before it is shipped. If delivery is delayed for any reason, your order
will not be reprocessed until 15 days from the original shipping date.
For further information, contact CVS/Caremark at the number listed in the Important Contact Information section.
8.09 Specialty Pharmacy Program
Specialty drugs are prescriptions used to treat complex and chronic health conditions. To receive coverage for
specialty drugs, you must have your prescription filled through the Specialty Pharmacy Program, which is a
mail-order pharmacy that will ship your specialty medications directly to you or, if you prefer, to a CVS/Caremark
Pharmacy. When you are prescribed a specialty medication, contact CVS/Caremark to enroll in the program. Once
you enroll in the program, your medications will be sent directly to your home, work or a CVS/Caremark pharmacy via
safe, temperature controlled and tested packaging at no additional cost. The amount of your copayment for specialty
drugs are the preferred or non-preferred copayments, as appropriate, and are listed in the Schedule of Benefits.
If you do not purchase your specialty drugs through the Specialty Pharmacy Program, the cost of your prescription
specialty drugs will not be covered by the Plan.
52
Specialty Step Therapy Program
The specialty step therapy program encourages the use of preferred drugs over non-preferred drugs. Under the
program, you may be asked to try a lower-cost preferred drug before the non-preferred drug will be dispensed. If
you are asked to try a lower-cost preferred drug and it is determined to be Medically Necessary for you to continue
to use a non-preferred specialty drug, you will be responsible for paying the non-preferred copayment. However, if
the preferred drug is an option for you, but you continue to use the non-preferred drug, you will be responsible for
paying the full cost of the non-preferred specialty drug.
For further information, contact CVS/Caremark at the number listed in the Important Contact Information section.
8.10 Covered Prescription Drug Expenses
Unless otherwise excluded under the Plan, the Prescription Drug Benefit covers Medically Necessary prescriptions
prescribed by a Physician. For a complete list of covered prescription drugs, you may contact CVS/Caremark. The
following are examples of covered prescription drugs:
• All federal legend drugs;
• State restricted drugs;
• Contraceptives as required under federal law;
• Injectable insulin; and
• Syringes and hypodermic needles in quantities compatible with the number of doses of insulin prescribed
(Note: You must fill the insulin order first for the syringes to be covered by the Plan).
8.11 Non-Covered Prescription Drug Expenses
The following expenses are not covered under the Plan:
• Drugs you can purchase without a prescription, except as required by the Aordable Care Act.
• Over-the-counter medication or medical supplies other than diabetic supplies or as required by the Aordable
Care Act.
• Experimental or Investigational drugs.
• Charges for the administration of prescription drugs or injectable insulin.
• Drugs taken by or administered to an individual in whole or in part while an inpatient in a hospital or other health
care facility licensed for dispensing pharmaceuticals (such drugs may be covered under the medical benefit).
• Prescription drugs that may be properly received without charge under local, state or federal programs, including
Workers’ Compensation.
• Renova (Tretinoin).
• Imcivree (Setmelanotide).
• Gene therapy drugs (including but not limited to Luxturna (voretigene neparvovec-rzyl), Yescarta (Axicabtagene
ciloleucel)).
• Lifestyle drugs such as drugs treating weight loss (except for weight loss drugs when approved as medically
necessary by the Claims Administrator) and/or hair loss.
• Drugs prescribed for erectile dysfunction (ED) more than six (6) doses per month.
• Compound drugs.
• Opioids beyond the Morphine Milligram Equivalent (MME) quantity limit.
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• 501K pathway devices, including, but not limited to, bandages, infusion pumps, pacemakers, wound care and
durable medical equipment.
• Vision enhancement agents.
• Prescription digital therapeutics.
• Expenses for drugs obtained through another medical or prescription drug plan (no coordination of benefits).
• Drugs for which a required prior authorization has not been approved.
• Charges for more than the number specified by the prescriber for a 30-day supply (90-day supply for
maintenance drugs).
• Any refill of a prescription drug dispensed more than one (1) year after the date of the prescription.
• Prescriptions purchased at a Non-Network Pharmacy.
• Any drug that is not approved by the Federal Drug Administration (FDA) or that is used for a non-FDA approved
purpose.
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SECTION 9: DENTAL BENEFITS
9.01 Eligibility Requirements
The Dental Benefit applies to you and your Dependents if you are an Active Employee or Retiree, and you are eligible
for medical benefits under the Plan.
9.02 Network and Non-Network Providers
The Blue Cross Blue Shield BlueCare® Dental Preferred Provider Organization (“Dental PPO”) network allows you
and/or your eligible Dependent(s) the freedom to choose any Dentist when you need dental care. You will maximize
your dental benefits when you visit a general or specialty Dentist through the Dental PPO network because Network
Providers have agreed to accept a negotiated rate for their services. Advantages of using Dentists in the Dental PPO
network include the following:
• Reduced out-of-pocket costs due to discounted fees;
• No Balance Billing;
• No referral needed for specialty Dentists; and
• Network Provider will submit claims for you.
Your annual maximum for dental benefits remains the same regardless of whether you select a Dentist from within
or outside the network. If you choose to receive services from a Non-Network Provider, the Plan will pay a percentage
of the charges for Covered Services, based on Eligible Charges, up to the maximum annual benefit, depending on the
services received. The Eligible Charges are the Usual and Customary Rates. You may also be balance billed by Non-
Network Providers for Covered Services.
9.03 Payment of Dental Benefits
Covered dental expenses are considered to have been incurred on the day the service is provided. When the
complete service is not performed in one day, only the expense for that portion of the completed service will be
considered incurred.
You will be responsible for the applicable percentage of covered expenses as listed in the Schedule of Benefits, up to
the maximum annual benefit limit. You will be responsible for the full cost of any services incurred after the limit has
been met. If you choose a Non-Network Provider, you may be responsible for any amount above the Eligible Charges.
9.04 Dental Expenses Covered by the Plan
Benefits are based on a calendar year, beginning in January and ending in December. The Plan covers the following
types of dental services:
Preventive and Diagnostic Services
• Application of dental sealants for Dependent Children up to age 16.
• Dental x-rays (bitewings limited to two (2) per calendar year; full mouth limited to once every 36 months).
• Fluoride applications for Dependent Children up to age 19.
• Oral examination, limited to two (2) times in a calendar year.
• Teeth cleaning, scaling and polishing, limited to two (2) times in a calendar year.
• Additional cleanings (up to four (4) per year) to treat periodontal disease with a letter of Medical Necessity for
Dependent Children up to age 19.
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Basic and Major Services
• Addition of teeth to an existing removable partial or full denture or fixed bridgework, or its total replacement, if
made necessary by drifting of anchor teeth.
• Artificial tooth implants.
• Crowns and initial installation of fixed bridgework.
• Extractions and oral surgery.
• Surgical removal of complete bony impacted teeth.
• Fillings and inlays.
• General anesthesia for dental procedures when Medically Necessary.
• Initial installation of removable or partial or full dentures.
• Orthodontia (as described below under “Orthodontia Services”).
• Repair or recementing of crowns, inlays, bridgework or dentures.
• Treatment for tooth damage that results from the grinding or biting of teeth (occlusal services).
• Treatment of diseases of the gums and tissue of the mouth.
9.05 Dental Expenses Not Covered by the Plan
The Plan does not cover the following types of dental services:
• Any work performed directly by a laboratory and billed to you without a prescription from a Dentist: such as
manufacture or repair of dentures, liners or other devices and appliances; or services and supplies of any kind
furnished directly by a lab.
• Treatment by someone other than a Dentist or Physician. The Plan will cover teeth cleaning by a licensed dental
hygienist who is supervised by a Dentist.
• Services and supplies that are solely for cosmetic reasons, such as bonding or whitening.
9.06 Orthodontia Services
When your eligible Dependent Child needs orthodontic care, he or she must visit a licensed orthodontist or Dentist.
The Plan pays a percentage of the charges for Covered Services, up to a lifetime maximum, as listed in the Schedule
of Benefits. There is no Deductible.
Orthodontic Services
Orthodontic procedures and treatment include examination records, tooth guidance repositioning (straightening)
and retention of the teeth for Dependent Child(ren) covered for orthodontics as shown in the Schedule of Benefits.
Covered services include limited, interceptive, and comprehensive orthodontic treatment, which all accumulate to
the lifetime maximum.
Special Provisions Regarding Orthodontic Services:
• Orthodontic services are paid over the course of treatment, up to the maximum orthodontic benefit, as shown in
the Schedule of Benefits. Benefits cease when the Dependent Child is no longer covered, regardless of whether
the entire benefit has been paid.
• Orthodontic treatment starts on the date the bands or appliances are inserted.
• Payment for diagnostic services performed in conjunction with orthodontics is applied to the orthodontic benefit
and subject to the maximum benefit, as shown in the Schedule of Benefits.
56
• If orthodontic treatment is terminated for any reason before completion, benefits will cease on the date of
termination.
• If the Dependent Child’s coverage is terminated prior to the completion of the orthodontic treatment plan, you are
responsible for the remaining balance of treatment costs.
• For services in progress on the Dependent Child’s coverage eective date, benefits will be reduced based on the
benefits paid prior to this coverage beginning.
Payment of Orthodontia Services
Generally, an orthodontist establishes the total cost of his or her services, supplies and appliances before treatment
starts. This is paid by an initial down payment with regular monthly payments thereafter. You are responsible for the
initial down payment. The Plan will consider a maximum of 16% of the total treatment fee and will pay 80% of that as
reimbursement for the down payment. Benefits for the remaining amount of the treatment plan would be spread out
and paid over the remaining treatment months or until the Plan’s lifetime maximum is paid, or the Dependent Child is
no longer eligible under the Plan; whichever occurs first.
For example: If your Dependent Child’s total treatment fee is $8,000 and you pay $4,000 as your downpayment, the Plan
would calculate 16% of $8,000 ($8,000 x 16% = $1,280). The Plan would pay $1,024 (80% of $1,280). The remaining
balance of $6,720 ($8,000 - $1,280) would be divided equally by the months of treatment and would be eligible for
reimbursement based on 80% of the monthly treatment fee, up to the lifetime maximum, assuming the Dependent Child
remained covered by the Plan.
To receive monthly reimbursements, you must:
• Continue to qualify as a Participant and your Dependent Child must remain covered under the Plan; and
• Submit paid receipts from your orthodontist for your monthly payment.
• You cannot receive your total reimbursements in less than 24 months, unless your Dentist certifies that the
orthodontia correction is completed.
Orthodontia Expenses Covered by the Plan
If it is determined to be Medically Necessary by the utilization review organization, an eligible Dependent Child
under the age of 19 will no longer be subject to the lifetime maximum for orthodontic dental care. However, if the
Dependent Child is age 19 to age 26, the Plan’s lifetime maximum indicated in the Schedule of Benefits will apply
even if the orthodontia dental care is Medically Necessary.
Orthodontia expenses that are not considered Medically Necessary will be subject to the Plan’s lifetime maximum.
Orthodontia Expenses Not Covered by the Plan
The Plan does not cover the following orthodontia expenses:
• Expenses incurred by someone other than an eligible Dependent Child.
• Replacement or repair of an orthodontic appliance.
• Services and supplies that are solely for cosmetic reasons.
• Treatment by someone other than a licensed orthodontist or Dentist.
SUMMARY PLAN
DESCRIPTION
57
SECTION 10: VISION BENEFITS
10.01 Eligibility Requirements
The Vision Benefit applies to you and your Dependents if you are an Active Employee or Retiree, and you are eligible
for medical benefits.
10.02 Network and Non-Network Vision Providers
The Plan has contracted with Vision Service Provider
(“VSP”) to provide services and supplies to you and
your Dependents at discounted rates through Network
Providers. You will maximize your vision benefits
when you visit a licensed optician, optometrist or
ophthalmologist through the VSP network because
Network Providers have agreed to accept a negotiated
rate for their services. Advantages of using the VSP
network include the following:
• Reduced out-of-pocket costs due to
discounted fees;
• No Balance Billing;
• Providers will submit claims for you (claims for Network Providers must be submitted within one (1) year of when
the expense was incurred); and
• Discounted prices on all your vision care needs, including those that are not covered by the Plan, such as extra
supplies and laser vision correction services.
To locate a Network Provider near you, please contact:
Vision Service Plan (VSP)
Member Services at 1-800-877-7195
Website at www.vsp.com
10.03 Payment of Vision Benefits
You will be responsible for any applicable copayment listed in the Schedule of Benefits. You are also responsible for
paying for any expenses that the Plan does not cover, including costs that exceed the maximum benefit or allowance.
There is no Deductible.
For services from a Network Provider, the Plan pays the cost of Covered Services after you pay your applicable
copayment listed in the Schedule of Benefits. For Non-Network Providers, the Plan will reimburse you for part of your
expenses for eye exams, frames and lenses, after you have paid your applicable copayment, in accordance with the
Schedule of Benefits.
If you choose to receive services from a Non-Network Provider, be aware that Non-Network Providers may balance
bill you for Covered Services. In addition, you must submit claim forms within six (6) months of the date the expense
was incurred for Non-Network Providers. When you submit claim forms, you must include receipts.
EIT Vision Clinic
Visit the EIT Vision Clinic in Alsip and you will receive a:
• WellTech Exam
• WellTech Fit
• FREE Retinal Imaging
• FREE Adjustments
• 90-Day Guarantee
• Excellent Customer
Service
Call (312) 795-5841 or visit www.vsponsiteclinic.com/eit
to make an appointment.
58
10.04 Vision Expenses Covered by the Plan
Benefits are based on a calendar year, beginning in January and ending in December. The Plan covers the following
types of Medically Necessary vision services:
• Complete vision analysis, including eye exam, refraction, visual therapy and case history.
• Contact lenses, up to the allowance listed in the Schedule of Benefits, and a contact lens exam (including fitting
and evaluation).
• Frames, up to the allowance listed in the Schedule of Benefits for a single pair, with additional savings on the
cost that exceeds the amount over the allowance. Participants only are eligible for a second pair of prescription
eyewear. Frames for Dependent Children under age 19 will be covered at 100% after the applicable copayment.
• Lenses, fully covered for single vision, lined bifocal, lined trifocal, lenticular, progressive, or polycarbonate lenses
or photochromic adaptive lenses and tints.
Additional savings may be available for sunglasses and additional eyewear, including lens enhancements, from the
same Network Provider on the same day as your vision exam.
10.05 Vision Expenses Not Covered by the Plan
The Plan does not cover the following types of vision services:
• Any type of lenses, frames, services, supplies or options that are not specifically listed as covered.
• Any surgical treatment in place of corrective lenses such as LASIK, photorefractive keratectomy (“PKR”)
or radial keratotomy (“RK”).
• Claims for a Network Provider filed more than one (1) year after the date the expense was incurred.
• Claims for a Non-Network Provider filed more than six (6) months after the date the expense was incurred.
• Non-prescription lenses.
• Replacement of lost or stolen glasses, or broken frames beyond the annual limit listed in the Schedule of Benefits.
• Services in connection with vision therapy, orthoptics, vision training, aniseikonia, or medical or surgical
treatment of the eye, unless performed by a Physician or licensed therapist.
SUMMARY PLAN
DESCRIPTION
59
SECTION 11: HEALTH REIMBURSEMENT
ARRANGEMENT
The Health Reimbursement Arrangement (“HRA”) is designed to allow you and your eligible Dependents to obtain
reimbursement of Eligible Expenses (as defined below) on a tax-free basis. The HRA is employer-funded and
administered and managed by HealthEquity.
Eective January 1, 2019, you may submit requests for and receive reimbursements from your HRA to cover Eligible
Expenses that are not otherwise covered under the Plan.
11.01 Eligibility
The HRA is a notional account established for each Active Employee for whom the Plan receives contributions under
a Collective Bargaining Agreement or participation agreement. If you are eligible for coverage under the Plan as
an Active Employee or Retiree or based on disability-related hour credits, self-payments or COBRA coverage, you
may utilize your HRA credit balance to pay for Eligible Expenses (defined below) incurred by you and your eligible
Dependents, provided you are covered on the date the Eligible Expense was incurred.
You may continue to utilize your HRA credit balance as long as you remain eligible for medical benefits under the
Plan. If you are not eligible for Retiree Health Benefits, you may utilize your HRA credit balance once you become
eligible for Medicare.
11.02 Suspension of HRA
If you are not otherwise eligible for medical benefits under the Plan and you do not choose to elect COBRA coverage,
then your HRA will be suspended. You may not submit or receive reimbursements from your HRA credit balance
for Eligible Expenses incurred while your HRA is suspended. However, any contributions the Plan receives under a
Collective Bargaining Agreement or participation agreement will still be allocated to your HRA.
Your HRA will remain suspended until one of the following events occurs:
• You reestablish eligibility for coverage under the Plan.
• You become eligible for Medicare.
• Your HRA is ultimately forfeited under the terms of the Plan (as explained below).
11.03 HRA Funding
Your HRA is a notional account funded by contributions made on your behalf pursuant to a Collective Bargaining
Agreement or participation agreement for each clock hour reported by your Employer. An HRA contribution will not
be made for any amounts received by the Plan as self-payments, and no contributions will be made to your HRA if you
are not performing work covered under a Collective Bargaining Agreement or participation agreement.
The Fund Oce keeps track of your HRA credit balance as a bookkeeping entry, which is adjusted at the discretion
of the Trustees. The Trustees manage and control the assets in which the HRA credit balances are invested (“HRA
Investment Fund”). The HRA Investment Fund is valued at fair market value annually for net earnings, losses,
appreciation, depreciation and forfeitures. Any adjustment to your HRA credit balance is made in accordance with
the Policy for Allocation of HRA Investment Fund Earnings/Losses and Forfeitures, which is available upon written
request to the Fund Oce, and which may be amended from time to time at the sole discretion of the Trustees.
60
If the Fund issues a reimbursement to you for an Eligible Expense from your HRA credit balance, your HRA credit
balance will be reduced by the amount of such reimbursement. Your HRA credit balance will be carried over from
year to year, except as specified below.
11.04 No Vesting of HRAs
HRAs are not savings accounts from which you can withdraw at will. You and your Dependents are not vested in your
HRA credit balances. Amounts accumulated in your HRA can only be used for Eligible Expenses, subject to the rules
and provisions set forth in this section.
Benefits payable under the HRA shall not be subject in any manner to alienation, sale, transfer, assignment, pledge,
attachment or encumbrance of any kind, except as required under applicable law.
11.05 Crediting of Reciprocal Contributions
If you work outside the jurisdiction under a reciprocity agreement and you elect to transfer your contributions to the
Plan, your contributions will first be applied to maintain your eligibility under the Plan. Any excess amount above
Local 134’s “core” contribution rate will be allocated to your HRA.
Core Contribution Rate
The “core” contribution rate is calculated by subtracting the HRA allocation from Local 134’s health and welfare
contribution rate.
11.06 Eligible Expenses and Reimbursements
Your entitlement to reimbursement from your HRA and the amount of any such reimbursement will be based on your
HRA credit balance at the time the reimbursement is requested and your eligibility for benefits under the Plan on the
date of service. You may receive reimbursement from your HRA only for Eligible Expenses. An expense is an Eligible
Expense if it satisfies the following requirements:
• The expense is incurred on or after June 1, 2018;
• The expense is incurred by an eligible individual while covered under the Plan (including any periods during which
coverage is extended because of self-payments, disability-related credit hours or COBRA coverage) or Medicare;
• The expense is not payable under any other benefit provisions of the Plan, has not been and will not be
reimbursed by other insurance or any other source, and has not been and will not be claimed as a tax deduction;
and
• The expense is an “Eligible Expense” (as defined below).
Eligible Expense
To be an Eligible Expense, the expense must be a “qualified medical expense” under Section 213(d) of the Internal
Revenue Code of 1986, as amended (“IRC”). Examples of a “qualified medical expense” include the following:
• Self-payments, including COBRA coverage self-payments and Retiree Self-Pay Contributions;
• Deductibles and copayments under the Plan;
• Medical expenses not covered by or in excess of the benefits provided under the Medical Benefit;
• Expenses for dental treatment, including orthodontia;
SUMMARY PLAN
DESCRIPTION
61
• Prescriptions and over-the-counter medications. Such items shall not include toiletries, sundries or cosmetics;
• Guide dogs for blind or deaf persons;
• Certain travel expenses of the patient when necessary to receive essential medical care, and the travel and
lodging expenses of another family member whose presence is necessary for the treatment. The patient’s
Physician must certify that the family member’s presence is necessary for the treatment;
• Special telephone and television equipment for hearing-impaired persons;
• Hearing aids and examinations;
• Smoking cessation programs;
• Vision expenses, including surgery or laser treatments to correct vision;
• Schooling for the mentally impaired or physically disabled;
• Acupuncture; and
• Weight loss programs, but not food or dietary supplements.
For a complete list of IRS Section 213(d) eligible expenses, please visit www.irs.gov/pub/irs-pdf/p502.pdf. However,
note that just because an expense is listed in Publication 502 does not automatically make it an Eligible Expense
under the HRA rules.
Expenses That Do Not Qualify as Eligible Expenses
No reimbursement will be made from your HRA for expenses that are not Eligible Expenses (i.e., do not qualify as
“qualified medical expenses” in Section 213(d) of the IRC). Some examples of expenses that are not covered include
the following:
• Athletic club, health and/or spa or gym memberships;
• School fees for boarding schools or school fees not related to a medical necessity;
• Cosmetic surgery, procedures and supplies;
• Health programs oered by resort hotels, health clubs and gyms;
• Child and elder care;
• Funeral expenses;
• Hair transplants;
• Household help other than that qualifying as long-term care;
• Personal use items;
• Premiums for coverage through a state or federal Health Insurance Marketplace; and
• Teeth whitening.
11.07 Reimbursements
Reimbursements from your HRA are subject to the following requirements:
• You must submit a claim for reimbursement of any Eligible Expense by either: (1) using your Health Equity debit
card to pay for eligible expenses at the time of service; or (2) submitting a reimbursement form, along with a copy
of your Explanation of Benefits (“EOB”) or other itemized receipts to Health Equity through the EZ Receipt app,
online or by fax or mail.
• HRA reimbursement requests can only be submitted by you or by your Dependent spouse pursuant to your
written authorization on file at the Fund Oce or, in the event you are deceased, by your surviving Dependent(s).
HRA reimbursement requests may not be submitted by a former spouse (unless your former spouse has elected
62
COBRA), and an HRA credit balance is not subject to division pursuant to a domestic relations order under the
preemption provisions of ERISA Section 514.
• HRA reimbursement requests must be submitted within 365 days from which the Eligible Expense was incurred.
Note that the expense is incurred on the date you received services or items for which you were charged the
expense, not the date of payment or invoicing.
11.08 Your Right to Opt-Out
You may choose to permanently opt-out of your HRA and forfeit your right to reimbursement from your HRA at any
time by notifying the Fund Oce in writing. Any credit balance in your HRA as of the date the Fund Oce receives
notice of such opt-out will be permanently forfeited. Any notice of opt-out received by the Fund Oce is irrevocable.
You will not receive any increase in your other benefits under the Plan as a result of opting-out of the HRA.
11.09 Forfeiture of HRA Credit Balance
Your HRA credit balance will be forfeited on the earliest to occur of the following:
• You lose eligibility under the Plan for one (1) year and your HRA credit balance is less than $25.00;
• You lost eligibility under the Plan for a period of two (2) consecutive years and your HRA credit balance is
between $25.00 and $49.99;
• You lose eligibility under the Plan for a period of three (3) consecutive years and your HRA credit balance is
between $50.00 and $74.99;
• You lose eligibility under the Plan for a period of four (4) consecutive years and your HRA credit balance is
between $75.00 and $99.99;
• You attained age 80, you have not submitted a claim for reimbursement for at least one (1) year and your HRA
credit balance is less than $25;
• The Fund Oce receives written notice that you irrevocably elect to opt-out of the HRA; or
• You die and you have no surviving Dependent on the Plan at the time of your death.
11.10 Payment of HRA Credit Balance upon Your Death
If you have a credit balance in your HRA upon your death and have eligible Dependents, your surviving spouse
may use your HRA credit balance for his or her Eligible Expenses or for any surviving eligible Dependent covered
under the Plan at the time of your death, by submitting reimbursement requests to the Fund Oce. If there is no
surviving spouse or your surviving spouse dies, then the remaining balance will be divided equally between the
surviving eligible Dependent(s) at the time of death. The eligible Dependent may then use the HRA credit balance by
submitting reimbursement requests.
If you die and you have no surviving Dependents, your HRA credit balance, if any, will be forfeited. Any remaining
balance in an eligible Dependent account will be forfeited upon the eligible Dependent’s death. The HRA is a notional
account and cannot be paid out, except in the form of reimbursement for Eligible Expenses incurred by you or your
eligible Dependents.
SUMMARY PLAN
DESCRIPTION
63
SECTION 12: DISABILITY BENEFITS
The Plan provides you with disability coverage that gives you and your family protection against some of the financial
hardships that can occur if you become Disabled or injured. The benefits include Short-Term Disability Benefits and
Long-Term Disability Benefits.
12.01 Disability Related Hour Credits
If you are unable to work because of a disability, you may be credited with up to 25 hours for each week of proven
disability while eligible for Short-Term Disability or Long-Term Disability Benefits during any one period of continuous
disability.
To receive credited hours, you must be:
• Receiving Short-Term Disability or Long-Term Disability Benefits from the Plan or disability benefits from your
employer’s Workers’ Compensation insurance; or
• Eligible for but not receiving benefits from the Plan because Social Security disability benefits are greater.
Eligibility credit will be given for up to 118 weeks if you were continuously covered under the Plan (not including
COBRA coverage) for at least 12 consecutive months, or 7 of the last 8 consecutive coverage quarters prior to the
date of your disability, or for up to 14 weeks if you were covered for fewer than 12 consecutive months prior to your
disability (not including COBRA coverage).
12.02 Limitations and Exclusions
You will not receive either Short-Term Disability or Long-Term Disability Benefits for any period of disability:
• During which you are not under the regular care of a Physician;
• During which your disability is not certified by the case management service;
• For which you are paid by an employer;
• That results from an accident while intoxicated or under the influence of narcotics not administered by a
Physician;
• That occurs after the date you retire;
• During which you are covered under COBRA continuation coverage; or
• That results from any of the circumstances listed under the General Plan Limitations and Exclusions section
of the Plan.
12.03 Short-Term Disability Benefits
Eligibility Requirements
If you are an Active Employee and you are eligible for coverage under the Plan at the time of your disability (not
including COBRA coverage), you may be eligible for Short-Term Disability Benefits. To be eligible for Short-Term
Disability Benefits you must be Disabled under the terms of the Plan.
To receive Short-Term Disability Benefits, the Fund Oce must receive your application for short-term disability
benefits within 90 days of the later of (1) the date you last worked Contributed Hours, or (2) the date of your injury
or illness.
64
Payment of Short-Term Disability Benefits
Your Short-Term Disability Benefits will start on the eighth consecutive calendar day of your disability. If you remain
Disabled, payments will continue for up to 13 weeks, but not beyond the date your Physician allows you to return to
work.
The amount of the Short-Term Disability Benefit payable is listed in the Schedule of Benefits. You will receive your
Short-Term Disability benefit at the end of each pay period during which you have provided proof of your continuing
disability. As required by federal law, Social Security and Medicare taxes will be withheld from your weekly Short-
Term Disability Benefit check. If you want federal income and state taxes withheld from your check, you must notify
the Fund Oce.
Benefits will be paid for no more than two (2) periods of disability during any rolling, or consecutive, 60-month period.
Recurring Disabilities
If you recover from a Short-Term Disability, return to work and are later Disabled again from the same cause, the two
periods will count as one period of disability, unless your Physician released you for full-time unrestricted work and:
• The disabilities are separated by four consecutive weeks of full-time employment where you are doing the same
or similar work as you did before your disability; or
• You are registered with the Referral Hall and Available for Work and did not turn down gainful employment for at
least four consecutive weeks.
If you recover from one Short-Term Disability and then become Disabled from a dierent cause, you will receive
benefits for up to 13 weeks for each period of disability if:
• Your Physician allowed you to return to full-time unrestricted work between the two periods of disability; and
• You either returned to full-time unrestricted work or registered with the Referral Hall and were Available for Work
and did not turn down gainful employment.
For Example – Recurring Short-Term Disability – One Period: You hurt your arm and qualify as Disabled on March 1.
On March 9, payment of your Short-Term Disability Benefit begins. Your Physician authorizes you to return to full-time
unrestricted work on April 19, which you do. At this point, you have received Short-Term Disability Benefits for seven
weeks. Three weeks later, on May 3, you reinjure your arm and qualify as Disabled. Since these two disabilities (from the
injury on March 1 and the injury on May 3) are not separated by four weeks of full-time employment, the second disability
is considered part of the same period as the first disability, and you are eligible for only six additional weeks of Short-Term
Disability Benefits because the Plan only oers a total of 13 weeks of Short-Term Disability Benefits for each period of
disability.
For Example – Recurring Short-Term Disabilities – Multiple Periods: You hurt your leg at home and qualify as Disabled
on July 15. On July 23, payment of your Short-Term Disability Benefit begins. Your Physician authorizes you to return to
full-time unrestricted work on September 24, which you do. At this point, you have received Short-Term Disability Benefits
for nine weeks. On March 10 of the following year, you injure your arm through a cause unrelated to your leg injury the year
before, and you qualify as Disabled. Since more than 4 consecutive weeks of full-time unrestricted work have elapsed,
you must begin a new disability claim. You receive ten weeks of Short-Term Disability Benefits on your new claim. Your
Physician authorizes you to return to full-time, unrestricted work on May 19. Since the Plan has provided Short-Term
Disability Benefits for two separate periods of disability, you are not eligible for any further Short-Term Disability Benefits
until five years after the original July 15 disability.
SUMMARY PLAN
DESCRIPTION
65
12.04 Long-Term Disability Benefits
Eligibility Requirements
If you are an Active Employee and you have been continuously covered under the Plan for the 12-consecutive month
period before the date your disability began (excluding COBRA coverage) or seven (7) of the last eight (8) consecutive
Coverage Quarters before the Short-Term Disability eective date, you may be eligible for Long-Term Disability
Benefits.
To be eligible for Long-Term Disability Benefits, you must:
• Have exhausted your Short-Term Disability Benefits;
• Be Disabled under the terms of the Plan;
• Not have engaged in any gainful employment for 14 consecutive weeks; and
• Have an application for Social Security Disability Insurance benefits pending (if your disability has lasted at least
five months) or be eligible to receive Social Security benefits.
The Fund Oce determines disability and the right of any participant to receive disability benefits from the Plan.
Applying for Social Security Disability Benefits
If your disability is expected to last 5 months or longer, you must have applied for Social Security Insurance Disability
benefits to be eligible for Long-Term Disability Benefits under the Plan.
Payment of Long-Term Disability Benefits
Your Long-Term Disability Benefits will automatically start after 14 weeks of disability (inclusive of the waiting period)
provided you meet the requirements for Long Term Disability benefits. If you remain Disabled, payments will continue
for up to 24 months, but not beyond the date your Physician allows you to return to work. Your payments will also end
when you receive a disability award from Social Security and elect to receive a disability pension from Pension Plan
No. 2 or have attained normal retirement age with Social Security and will not be eligible for an SSDI award based on
your age.
The monthly amount of the Long-Term Disability Benefit is listed in the Schedule of Benefits and based on the formula
shown below:
60% of your average monthly pay
(subject to a $2,000 minimum benefit; $3,000 maximum benefit)
MINUS
Any disability benefits paid or payable by Social Security or any other group disability plan
For Example – Since your benefit is 60% of your average monthly pay, if your average monthly pay is $3,333 or less, your
monthly benefit will be $2,000. If your monthly pay is between $3,333 and $4,999, you will receive 60% of your average
monthly pay. If your average monthly pay is at least $5,000, your maximum benefit is $3,000 per month, reduced, in all
cases, by any amount of disability benefits payable by Social Security or any other group disability plan.
66
Vacation and holiday pay, bonuses and commissions are not included in calculating your average monthly pay for
purposes of your Long-Term Disability Benefit.
Rehabilitative Employment
Your Long-Term Disability Benefit will continue if you participate in rehabilitative employment, but it will be reduced
by 80% of your income from such employment. The reduction may apply for the whole 24-month benefit period.
Average Monthly Pay
Average monthly pay means the wages or salary paid to you by participating employers in the 12 calendar months before
your disability began, divided by 12.
Recurring Disabilities
If you recover from a Long-Term Disability and then are considered Disabled again within six months from the same or
a related cause, you are considered to have a continuation of the first disability. If more than six months have passed
since your recovery, and you have worked doing the same or similar work for six consecutive months as you did before
your first disability, you are considered to have a new disability for which you may receive up to 24 months of benefits,
subject to a 14-week waiting period.
Social Security Disability Benefits (SSDI)
Social Security may also provide disability benefits to you and your eligible family members. You must apply for
a Social Security Disability Insurance (“SSDI”) benefit within five months of the onset of your disability to remain
eligible for Long-Term Disability Benefits under the Plan. You must provide the Fund Oce with a copy of the
confirmation from the Social Security Administration that the application was submitted. If your initial application for
SSDI benefits is denied, you must pursue your right to appeal the denial. This means you must complete each of the
following steps on a timely basis until you receive a final and non-appealable decision on your claim:
• A reconsideration;
• A hearing before an administrative law judge; and
• A review by an Appeals Council.
For each step, you must apply in writing within 60 days of notification that your appeal was not granted at the earlier
step.
After you have been determined to be eligible for SSDI benefits for 24 months, you become eligible for Medicare —
regardless of your age. This is another important reason to pursue your claim for Social Security benefits throughout
the entire appeals process.
Disability Advancement
While you wait for the Social Security Administration to make a final determination of your right to SSDI benefits, the
Trustees may grant an advancement from the Plan. This disability advancement is secured by your benefit under the
Plan or any other benefits that you may receive from the Trustees.
Prior to your sixth (6th) month of Long-Term Disability benefits, the Fund Oce will send you a “Disability
Advancement Agreement” for you to complete and return.
SUMMARY PLAN
DESCRIPTION
67
The disability advancement begins the first day of the 6th month from the date of initial disability. The amount
of the disability advancement is determined based on your estimated SSDI benefit from Social Security. If your
application for SSDI benefits is approved, the advancement portion must be paid back to the Plan within 30 days
after you receive an SSDI benefit.
If your application for SSDI benefits is not approved after you have completed the entire appeal process, as described
above, you will not be required to repay the disability advancement as there will be no retroactive benefits from SSDI
to oset the disability advancement.
If you will not be eligible for SSDI benefits because you have already reached your normal retirement age as
determined by the Social Security Administration, you will not be eligible for Long Term Disability payments after the
first month.
Coordination with Pension Plan Disability Benefits
If you become totally and permanently Disabled and have been granted an SSDI benefit from Social Security, you may
be eligible to receive benefits from Pension Plan No. 5 and/or Pension Plan No. 2. However, if you start your disability
pension from Pension Plan No. 2, you are no longer eligible for Long-Term Disability benefits under the Plan. Please
note, delaying these benefits may affect your eligibility for retroactive benefits under Pension Plan No. 2 and your
Retiree Health Benefits under this Plan. Please contact the Fund Oce for more information.
12.05 Coordination with Workers’ Compensation Claims
When you are hurt on the job, you are responsible for notifying the Fund Office of your injury as soon as possible.
Any delay in reporting the injury may result in benefits being denied. The Fund Oce will notify the Claims
Administrator of the injury and reject claims relating to the injury, as the Workers’ Compensation insurance carrier will
be responsible for payment of any claims relating to the injury or illness.
You must complete and file a Workers’ Compensation Disability Statement, available on the Fund Oce website,
within 90 days of the later of (1) the date you last worked Contributed Hours, or (2) the date of your injury or illness,
including contested Workers’ Compensation claims. Your employer may notify the Fund Oce if you file a Workers’
Compensation claim with its insurance carrier, however, it is ultimately your responsibility to ensure the Fund Oce
has been notified. Workers’ Compensation Disability Statements received after the 90-day deadline will be denied.
Credited Hours and Workers’ Compensation
If you become Disabled because of an occupational injury or illness and have been awarded Workers’ Compensation
benefits (even if you contest the amount of the Workers’ Compensation benefits), you are not eligible to receive any
disability payment under the Plan. You may, however, be eligible to receive hours credited towards your eligibility for
coverage under the Plan.
To receive disability-related credit, you must:
• Submit your Workers’ Compensation Disability Statement to the Fund Oce within the 90-day period described
above;
• Have been covered under the Plan at the time of your injury or illness (not including COBRA coverage); and
• Provide the Fund Oce with proof of continued payments from the Workers’ Compensation insurance carrier
along with an updated Attending Physician Statement quarterly, as requested. Failure to provide the necessary
documentation within 90 days of the request will result in a suspension of benefits. Your claim for Workers’
Compensation credited hours will be permanently closed if the requested documentation has not been received
by the Fund Oce within 180 days of the initial request.
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Disability related hours credit will be given for up to 118 weeks if you were continuously covered under the Plan for at
least 12 consecutive months before the date of your injury or illness (not counting any periods of COBRA coverage),
or for up to 14 weeks if you were covered for fewer than 12 consecutive months before your injury or illness (not
counting any periods of COBRA coverage).
Contested Workers’ Compensation Claims
If you filed a claim for Workers’ Compensation that has been denied, are not receiving or have never received
any Workers’ Compensation benefits from such claim and are appealing the denial with the applicable court or
governmental agency (“WCCGA”), you may be eligible to receive reduced Short-Term Disability Benefits and Long-
Term Disability Benefits under the Plan until your claim is ultimately denied or awarded by the WCCGA.
In such cases, you would be eligible to receive 50% of the Short-Term Disability payment for up to a maximum of 13
weeks and 50% of the Long-Term Disability payment for up to an additional 24 months if you meet all the following
requirements:
• You submit your application for Short-Term Disability Benefits within 90 days of the later of (1) the date you last
worked Contributed Hours, or (2) the date of your injury or illness;
• For Short-Term Disability payments, you were covered under the Plan at the time of your injury or illness (not
including COBRA coverage);
• For Long-Term Disability payments, you were covered under the Plan for 12 consecutive months before the date
of your injury or illness (not including COBRA coverage) or seven (7) of the last eight (8) consecutive Coverage
Quarters before the Short-Term Disability eective date;
• You execute a reimbursement agreement with the Trustees, which requires, upon receipt of any recovery
whatsoever for your injury or illness from whatever source, you agree to reimburse any Short-Term Disability
payments, Long-Term Disability payments and medical expenses paid by the Plan on account of the injury or
illness, and you agree that no reductions or deductions are allowed for litigation costs, court costs, or attorney’s
fees (i.e., the Illinois Common Fund Doctrine, Make Whole Doctrine, and/or any other state law aecting these
rights are preempted by the Plan provisions under ERISA);
• You provide proof of the denial by the Workers’ Compensation insurance carrier, proof of the appeal to the
WCCGA; and quarterly proof that you are unable to return to work;
• Your Workers’ Compensation claim is still pending before the WCCGA; and
• You satisfy all other requirements to qualify for Short-Term and/or Long-Term Disability Benefits, as appropriate,
under the terms of the Plan.
During the time that your Workers’ Compensation claim is contested and pending a final and non-appealable
decision, you will be credited disability related hours for purposes of determining eligibility for coverage under the
Plan, which will cover medical expenses for the injury or illness until a final and non-appealable decision is made as to
whether your injury or illness is determined to be work-related.
Final and Non-Appealable Decision
If your claim is ultimately denied by the WCCGA, your claim will be converted to a Short-Term Disability Benefit and/
or Long-Term Disability Benefit, as appropriate, and you will be paid the balance of disability payments not previously
paid to you.
SUMMARY PLAN
DESCRIPTION
69
If you are awarded any Workers’ Compensation benefits, regardless of classification, by any WCCGA, you must fully
reimburse the Plan for the disability payments made and the medical expenses covered for treatment related to the
injury or illness, consistent with the terms of the reimbursement agreement.
If you fully reimburse the Plan for the disability and medical expense payments made on your behalf during the time
your Workers’ Compensation claim was contested, the period of Short-Term Disability Benefits paid to you during the
time your Workers’ Compensation claim was contested will not count towards one of your two periods of Short-Term
Disability Benefits permitted within any rolling, or consecutive, 60-month period.
If you do not fully reimburse the Plan, amounts due to the Plan will be oset from any future benefit amounts
otherwise payable to you by the Plan to the extent permitted by law, including suspension of coverage. In addition,
this will be counted as one of your two periods of Short-Term Disability Benefits permitted within any rolling, or
consecutive, 60-month period.
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SECTION 13: MATERNITY LEAVE BENEFITS
If you are an Active Employee and are out of work due to your pregnancy, you may be eligible to receive Maternity
Leave Benefits under the Plan.
13.01 Eligibility Requirements
To qualify for Maternity Leave Benefits, you must be covered as an Active Employee by the Plan (not including
COBRA coverage) at the onset of your maternity leave. You cannot receive the Maternity Leave Benefit and the Short-
Term Disability Benefit or Long-Term Disability Benefit at the same time.
13.02 When Benefits Begin and End
Your Maternity Leave Benefits may begin no earlier than 13 weeks before your expected due date, except in the case
of delivery prior to 13 weeks. Total payments for Maternity Leave Benefits may not exceed 26 consecutive weeks.
13.03 Payment of Maternity Leave Benefits
You will receive the weekly benefit shown in the Schedule of Benefits for each period during which you are eligible
to receive the benefit. Because of federal law, Social Security and Medicare taxes will be withheld from your weekly
Maternity Leave Benefit. If you want federal income and state taxes withheld from your benefit payment, you must
notify the Fund Oce.
13.04 Maintaining Coverage While on Maternity Leave
If you are unable to work because of a verified maternity leave, you may be eligible to receive credit for five (5) hours
per day, for each day of maternity leave, up to a maximum of 25 hours per week. One credited hour of maternity leave
is equivalent to one accumulated Contributed Hour for purposes of determining eligibility under the Plan. Maternity
leave hour(s) will be credited for up to a maximum of 26 weeks.
13.05 Extended Leave Due to Disability
If your maternity leave has been exhausted, and you are unable to return to work due to a disability (whether due to
pregnancy or other reason), you may apply for Short-Term Disability Benefits. All eligibility rules, requirements and
payment amounts under the Short-Term Disability Benefit section would apply with respect to extended leave due to
disability, except for the 7-day waiting period, which would be waived in such cases. Please contact the Fund Oce
should you need further information or need to request a Short-Term Disability Benefit application.
SUMMARY PLAN
DESCRIPTION
71
SECTION 14: LIFE INSURANCE BENEFITS
14.01 Eligibility Requirements
If you are an Active Employee and you are eligible for coverage under the Plan at the time of your death, you qualify
for the Life Insurance Benefit. If you are a retiree who retired under Pension Plan 2 and have not attained age 65, and
you qualify for retiree health benefits under the Plan, you are also eligible for the Life Insurance Benefit.
The Board of Trustees has contracted with a third-party insurance carrier to provide the Life Insurance Benefit, and
this fully insured benefit will be paid in accordance with the terms of the insurance policy, which is incorporated by
reference into the Plan. In the event of a conflict between the terms of the Plan and the insurance policy, the terms of
the policy govern. If you wish to receive a copy of the insurance policy, please contact the Fund Oce.
Your Basic Life Insurance Benefit is paid to your Designated Beneficiary as a single lump-sum payment, provided he
or she is living on the earlier of the date the insurance carrier receives proof of death or the 10th day following your
death. The amount of the Life Insurance Benefit is shown in the Schedule of Benefits.
14.02 Designated Beneficiary
You may designate your beneficiary by completing and returning the beneficiary designation form available from the
Fund Oce. Your beneficiary designated in the beneficiary designation form (“Beneficiary Request”) will apply to
both the Life Insurance Benefit and the AD&D Benefit. You may change your beneficiary designation at any time by
filing a new beneficiary request form with the Fund Oce. To be valid, a completed beneficiary request form must be
received by the Fund Oce before your death, and beneficiary request forms are eective upon receipt by the Fund
Oce of an accurately completed beneficiary request form.
If you do not designate a beneficiary, or if your Designated Beneficiary is not living at the time of your death, your
death benefit will be divided equally among the then living members of the first surviving class listed below:
• Your spouse;
• Your children;
• Your parents; or
• Your estate.
14.03 Accelerated Death Benefit
If you are diagnosed with a terminal condition, you may receive the Accelerated Death benefit. A terminal condition
means that based on the nature and severity of your condition, your life expectancy is no more than 24 months. You
may receive this benefit while you are still living.
The Accelerated Death benefit is equal to 60% of the Basic Life insurance benefit. The remaining 40% of the
Accelerated Death benefit will be paid out to your Designated Beneficiary upon your death. The Accelerated Death
benefit is paid in one lump sum and paid only once. If an additional terminal diagnosis is given, the benefit cannot be
paid again.
To receive the Accelerated Death benefit, you must meet the following conditions:
• You must request this benefit in writing while you are still living. If you are unable to request this benefit yourself,
your legal representative may request it for you;
72
• You must be eligible for the Basic Life Insurance benefit;
• You must provide a doctor’s statement which gives the diagnosis of your medical condition and states that
because of the nature and severity of such condition, your life expectancy is no more than 24 months to the
insurance carrier. The insurance carrier may require that you be examined by a doctor of its choosing. If the
insurance carrier requires this, it will cover the cost of the exam; and
• You must provide written consent from any irrevocable beneficiary, assignee, and, in community property states,
from your spouse.
Please note that receipt of the Accelerated Death benefit may be considered taxable. You should consult your
personal tax advisor to assess the impact of this benefit. Additionally, the amount of your Basic Life Insurance benefit
will be reduced if you receive the Accelerated Death benefit.
14.04 Conversion Privilege
If your Basic Life Insurance benefit ends because your eligibility for this benefit ends or because the group insurance
policy terminates, you may purchase an individual life insurance policy from an insurance carrier designated by the
Board of Trustees without giving evidence of insurability. The Fund Oce will provide the Life Conversion Request
form in advance which includes premium and coverage information.
To use this conversion privilege, a written application and payment of the first premium must be made to and
received by the insurance carrier within 31 days after termination of coverage. The individual policy issued will be of
the form used by the insurance company for conversion of group life insurance at the time conversion is made. The
eective date will be the date following the date coverage ends under the Plan.
SUMMARY PLAN
DESCRIPTION
73
SECTION 15: ACCIDENTAL DEATH &
DISMEMBERMENT (AD&D) BENEFITS
15.01 Eligibility Requirements
If you are an Active Employee and you are eligible for coverage under the Plan, you are eligible for AD&D benefits.
The Board of Trustees has contracted with a third-party insurance carrier to provide the AD&D Benefit, and this fully
insured benefit will be paid in accordance with the terms of the insurance policy, which is incorporated by reference
into the Plan. In the event of a conflict between the terms of the Plan and the insurance policy, the terms of the policy
govern. If you wish to receive a copy of the insurance policy, please contact the Fund Oce.
The AD&D Benefit is payable to you if you sustain one of the losses listed in the Schedule of Benefits as a result of an
accident. The loss must have occurred within 180 days of the accident. To qualify as a loss, the severance of a limb
must occur above the wrist joint or ankle joint. Loss of sight means the total and permanent loss of sight. If more than
one loss (listed in the Schedule of Benefits) is sustained as the result of the same accident, benefits are paid only for
the loss that provides the greatest payment.
The AD&D Benefit is payable to your Designated Beneficiary if you die as a direct result of an accident and
independent of all other causes within 180 days of the date of the accident. The beneficiary designation rules for
the AD&D Benefit are the same as those for the Basic Life Insurance Benefit. For more information on designating a
beneficiary, see Section 14.02.
The types of losses covered under the AD&D Benefit and the corresponding benefit amounts are shown in the
Schedule of Benefits. The AD&D Benefit is in addition to any other benefits you may receive under the Plan.
15.02 Safe Driver Benefit
If you die while driving or riding in an automobile accident equipped with a factory installed airbag that operated
properly upon impact, the Plan will pay to your Designated Beneficiary a Safe Driver Benefit, which is in addition to
the full AD&D benefit amount. If loss of life occurs and you are wearing only a safety belt, your Designated Beneficiary
will be eligible for an additional 10% of the full amount of the AD&D benefit. If loss of life occurs and you are wearing a
seat belt and the air bag is deployed, the Plan will pay an additional 15% of the full amount of the AD&D benefit.
The Safe Driver Benefit will not be paid if the loss of life was directly caused by any use or intoxicating liquors,
marijuana, narcotic drugs, depressants or similar substances, whether or not prescribed by a doctor, by you or by the
driver of the automobile in which you were riding.
15.03 Coma Benefit
You may be eligible for a Coma Benefit if, due to an accident, you are in a coma. Coma Benefit payments will stop
when you are no longer in a coma or the maximum benefits have been paid, whichever comes first. The Plan will pay
you an additional 2% of the full AD&D benefit amount each month for up to 12 months up to the maximum full AD&D
benefit amount.
Coma means that you remain unresponsive to any stimuli and speechless for a period not less than 30 days, as
determined by a competent medical authority.
If you are physically and mentally incapable of receiving and cashing Coma Benefit payments, then the payments
instead will be made to the person legally authorized to receive the payments on your behalf.
74
15.04 Education Benefit
The Plan pays an Education Benefit in addition to the AD&D benefit and subject to the conditions below if you die
due to an accident. The amount of this benefit is 5% of the full AD&D benefit amount. This benefit will be paid to your
dependent who is enrolled as a full-time student in an accredited post-secondary institution of higher learning beyond
grade 12 within 365 days following the date of your death. It will be paid at the end of each annual period following
your death for up to 4 years to a maximum of $3,000 per year. Education benefits are paid to each eligible dependent
student, or to the dependent’s legal guardian.
Benefit payments will stop if either of the following is true during the preceding annual period:
• The student’s full-time school attendance is less than 6 months; or
• The student would no longer be considered your eligible dependent under the definition of dependent in the
policy.
15.05 Transportation Benefit
The Plan pays a Transportation Benefit in addition to the AD&D benefit if you die due to an accident that occurs at
least 75 miles from your primary residence. The amount of this benefit is 2% of the full AD&D benefit amount up to a
maximum of $2,000 and is payable to your beneficiary or beneficiaries.
15.06 Child Care Benefit
The Plan pays a Child Care Benefit in addition to the AD&D benefit if you die due to an accident, and your dependent
child under age 13 years is enrolled in a licensed day care center within 90 days of your death. This benefit is paid on
behalf of each eligible dependent child at the end of each annual period following your death. This benefit is in the
amount of 3% of the full AD&D benefit amount each year for up to 6 years and a maximum of $2,000 per year.
Benefit payments will stop if either of the following is true during the preceding annual period:
• Your dependent child does not attend a licensed day care center for at least 1,000 hours; or
• Your dependent child is not under age 13 for any part of that year.
Child Care Benefits are paid to the person who has incurred the cost of day care expenses for your eligible dependent
child.
15.07 Occupational Assault Benefit
The Plan pays an Occupational Assault Benefit in addition to the AD&D benefit if you suer a covered loss due to an
accident, and:
• The loss is due to an intentional and unlawful act of physical violence directed at you by another person;
• You are actively at work, performing assigned duties on behalf of the employer at the time of the assault; and
• A report of criminal activity has been filed on your behalf with the appropriate law enforcement authority within
48 hours of the assault
The benefit amount is the AD&D amount otherwise payable for this loss, up to a maximum of $10,000. Occupational
Assault benefits are paid to you if living, otherwise to your Designated Beneficiary.
SUMMARY PLAN
DESCRIPTION
75
15.08 Exclusions
The AD&D Benefit is not payable if death or dismemberment results from:
• Bacterial infection or bacterial poisoning (except infection from a cut or wound caused by an accident or
accidental ingestion of a poisonous food substance);
• Physical or mental illness;
• Suicide or intentionally self-inflicted injury, while sane or insane;
• Riding in or descending from an aircraft as a pilot or crew member;
• Any armed conflict, whether declared as war or not, involving any country or government;
• Injury suered while in the military service for any country or government Injury which occurs when you commit
or attempt to commit a felony;
• Use of any drug, narcotic or hallucinogenic agent –
– Unless prescribed by a doctor
– Which is illegal
– Not taken as directed by a doctor or the manufacturer; and
• Your intoxication. Intoxication means your blood alcohol content meets or exceeds the legal presumption of
intoxication under the laws of the state where the accident occurred.
76
SECTION 16: MEMBER ASSISTANCE PROGRAM
16.01 Eligibility
The Member Assistance Program applies to you and your Dependents if you are an Active Employee or Retiree and
you are eligible for medical benefits under the Plan.
16.02 Member Assistance Program
The Member Assistance Program (“MAP”) provides short-term counseling and assessment-referral services
to Participants and their families. Professional phone support is available 24 hours a day, 365 days a year, and
Participants and their families are eligible for up to three face-to-face counseling sessions per problem, situation or
issue at no additional cost.
MAP counselors will provide you and your eligible Dependents with short-term counseling and referrals for a variety
of work and life issues, including marital or family problems, parenting challenges, depression, anxiety, alcohol or
substance abuse, medical issues, financial and legal concerns, identity theft protection and recovery consultation,
and web-based work life resources.
All contact with the MAP is confidential. The MAP counselor will not speak with the Fund Oce, a supervisor, co-
worker or family member without permission from the person using the Member Assistance Program. Confidentiality
may be compromised only when a threat to life exists (e.g., suicidal or homicidal risk, stalking or child abuse).
SUMMARY PLAN
DESCRIPTION
77
SECTION 17: GENERAL PLAN LIMITATIONS AND
EXCLUSIONS
The following is a list of procedures, services, supplies and types of treatment for which Plan benefits are not payable
or for which the benefits are limited as indicated below. The following list is not all-inclusive or exhaustive; rather, it is
only representative of the types of services and supplies for which charges may be incurred which are not payable by
the Plan. Notwithstanding anything listed below, the Plan does not exclude charges for treatment of injuries resulting
from an act of domestic violence or medical condition.
• Charges for a Participant’s injury or illness arising from any electrical work or any other paid work finally
adjudicated to be payable (including lump sum settlements) under any Workers’ Compensation law or
occupational disease law.
• Charges for services or supplies provided by a person, facility or organization acting outside the scope of the
applicable license.
• Charges for care, treatment, procedures, services or supplies provided to a Dependent paid or payable under any
Workers’ Compensation law (whether performed for pay or not) or occupational disease law.
• Charges for care, treatment, procedures, services or supplies provided to a person who is not covered and/or
eligible under the Plan at the time such care, treatment, procedures, services or supplies are provided.
• Charges for services or supplies that are provided by hospitals or medical institutions owned or operated by a
federal, state or local government, or their medical practitioners, unless you are required to pay such charges.
• Charges caused by your voluntary participation in a riot.
• Charges caused by war or any act of war, whether declared or undeclared.
• Charges incurred during the commission of a felony or involvement in a criminal enterprise.
• Charges for treatment of any intentionally self-inflicted injury (except in cases of mental illness or relating to a
medical condition).
• Charges for travel or transportation except as otherwise specifically provided.
• Charges for services or supplies that are in the nature of education or vocational testing and training, except as
otherwise specifically provided.
• Charges ordered by a court, including without limitation court-ordered safety counseling courses.
• Charges incurred while in the military service of any country, or a civilian non-combatant unit serving with such
forces. However, the Plan will cover expenses as required under USERRA.
• Charges for which you do not have to pay (e.g., services provided without charge or paid through any other plan).
• Charges for Experimental or Investigational treatments and procedures.
• Charges for services and supplies that exceed the Eligible Charge.
• Charges for treatments received in any penal facility or jail or equivalent institution.
• Charges for any treatments, services or supplies furnished by a person who resides in your home, or who is a
member of your immediate family (i.e., your spouse, child, brother, sister or parent).
• Charges for failure to keep scheduled visits or appointments.
• Charges for completion of claim forms or other forms required by the Plan for processing of claims.
• Charges for reports or medical requests not requested by the Fund.
78
• Charges that would not have been made if the Plan did not exist.
• Charges for claims not received by the Fund Oce within one (1) year after the date the expense was incurred,
except as otherwise provided in the Plan.
• Charges incurred as the result of an injury or sickness for which a Participant has the right to recover payment
from a third party, except to the extent provided under the Plan’s reimbursement and subrogation procedures.
• Charges for treatment rendered outside the United States or its territories except if for non-work-related
emergency care or for Participants with established residence outside of the United States.
SUMMARY PLAN
DESCRIPTION
79
SECTION 18: COORDINATION OF BENEFITS
The Plan contains a coordination of benefits (“COB”) provision. This provision ensures that if you or your eligible
Dependents are covered by more than one group health plan, benefits from all plans combined will not exceed 100%
of the maximum allowable expense.
18.01 Other Plans Defined
The Plan coordinates benefits with the following types of plans:
• Group, blanket, or franchise insurance coverage;
• Any coverage under labor-management trusteed plans, union welfare plans, employer organization plans,
employee benefit organization plans, or any other arrangement of benefits for individuals or a group; or
• Any coverage required or provided by statute.
Prescription Drug Benefit
Prescription drug benefits under the Plan are not coordinated with any other coverage. You or your Dependents must
receive prescription drug benefits through the primary plan to have them covered.
18.02 Order of Benefit Payment
If you have a claim that is covered by two or more plans, the primary plan will pay its benefits first as if the other plan
does not exist. The other plan, or the secondary plan, will adjust its benefits so that the total benefits paid to you will
not be greater than the total allowable expense.
The Plan will not pay benefits for expenses which would have been covered by another plan, but which are not paid
because the person failed to follow the other plan’s rules. For example, if your Dependent is covered under a health
maintenance organization (“HMO”) and voluntarily elects not to follow their referral guidelines or procedures, no
benefits will be payable from the Plan.
A plan without a COB provision is always the primary plan. If all plans have COB provisions, the following rules apply:
• A plan that covers a person as an employee is primary
over a plan that covers the person as a dependent.
• A plan that covers a person as an employee is primary
over a plan that covers a person as a retired or laid o
employee.
• For a dependent child covered under both parents’
plans, the primary plan is determined as follows:
– The plan of the parent whose birthday (month and day) falls earlier in the calendar year is primary.
– If both parents have the same birthday, the plan that has covered the parent the longest is primary.
– If the other plan coordinates benefits based on the gender of the parents, the plan covering the male
parent is primary.
Claims for Secondary Coverage
If the provider will not submit a claim for
secondary coverage, it is your responsibility, as the
participant, to file the claim in a timely manner.
80
• For a dependent child whose parents are separated or divorced, the primary plan is determined as follows:
– If a court decree establishes financial responsibility for the child’s health care expenses, the plan of the parent
with financial responsibility is primary.
– If there is no court decree establishing financial responsibility, the plan covering the parent with custody of the
child is primary.
– If there is no court decree establishing financial responsibility and the parent with custody has remarried, the
order of payment is as follows:
⚬ The plan of the parent with custody is primary and pays benefits first
⚬ The plan of the stepparent with custody pays benefits second
⚬ The plan of the parent without custody pays benefits third
⚬ The plan of the stepparent without custody, if any, pays benefits fourth
• A plan that covers a person as a dependent spouse is primary over a plan that covers the person as a dependent
child. The Fund Oce requires a copy of the ID card from the other insurance to ensure proper coordination of
benefits.
• If you and your spouse are both covered as employees under the Plan, the Plan will coordinate benefits and will
pay primary employee benefits and secondary dependent benefits. In all other circumstances where a person
has multiple sources of eligibility for coverage under the Plan, such a person will receive only one set of benefits
under the Plan, as if the other source of eligibility did not exist.
• If a person who has COBRA coverage is also covered under another plan as an employee, retiree or dependent,
the COBRA coverage is secondary.
• If none of the above rules apply, the plan that has covered a person the longest is primary.
18.03 Right to Information and Recovery
The Plan has the right to receive and release necessary information to determine whether coordination of benefits
or any similar provisions apply to a claim. If the Plan makes larger payments than are necessary under the COB
provision, the appropriate claims administrator has the right to recover those excess payments. Recovery may be
made from any insurance company, any organization and/or any persons to or for whom those payments were made.
In the case of underpayment, the Plan may reimburse another plan directly instead of paying the person requesting
benefit payment.
18.04 Coordination with Medicare
Active Employees
If you are actively employed, regardless of your age, the Plan will be primary to Medicare for you and your eligible
Dependents. Benefits under the Plan are determined before Medicare’s benefits.
SUMMARY PLAN
DESCRIPTION
81
Retired or Disabled Employees
If you and/or your Dependents are entitled to Medicare due to age or disability, Medicare will have primary
responsibility, and the Plan will pay second. If you or your Dependents are entitled to Medicare benefits, the Plan
will pay benefits as though you are enrolled in Medicare Part A and Part B, regardless of whether you or your
Dependents are actually enrolled. If you and/or your Dependents do not enroll, you must pay the amount Medicare
would otherwise have paid (e.g., 80% of Medicare eligible expenses). The Plan does not cover the cost of Medicare
premiums. Therefore, you and/or your Dependents should enroll in both Medicare Part A and Part B at the earliest
possible opportunity.
Expenses not reimbursable by Medicare may be covered by the Plan if you have followed Medicare procedures.
You are required to seek treatment from a provider that has been approved by Medicare and is eligible to receive
reimbursement from Medicare. All Medicare eligible Retirees and Dependents MUST satisfy the calendar year
Deductible (as listed in the Schedule of Benefits) before the Plan will pay any benefits. Any expenses not approved
by Medicare because the person failed to follow any Medicare guidelines or procedures will not be covered.
If Medicare is the primary payer, the Plan will calculate its payment as if there was no Medicare coverage, and apply
the Deductible, Copayments and other Plan limits first. Then, the Plan will pay the remaining amount, minus what
Medicare will pay.
The process used in determining benefits under the Plan is as follows:
• Determine what the payment for a Covered Service would be under the Plan’s Schedule of Benefits.
• Deduct from the charges eligible under Medicare, the amount paid by Medicare. Note: If you are eligible for
Medicare, the amount that is available from Medicare will be deducted whether you have enrolled and/or received
payment from Medicare.
• The lesser of the two amounts determined in accordance with step 1 and step 2 above is the amount that will be
paid under the Plan.
Medicare Coverage for Individuals with End-Stage Renal Disease
If you and/or your Dependents are entitled to Medicare based solely on End Stage Renal Disease (“ESRD”), the Plan
will be primary to Medicare during the first 30 months of the person’s entitlement to Medicare. After the first 30
months of ESRD entitlement, Medicare will have primary responsibility, and the Plan will pay second.
82
SECTION 19: REIMBURSEMENT AND
SUBROGATION
19.01 Fund’s Right to Reimbursement
The Plan is entitled to 100% reimbursement of all medical, dental and disability claims paid on your behalf and/or
your Dependent’s behalf if any of the following applies:
• You or your covered Dependent recovers money from a “Third Party” (as defined below) for expenses incurred
due to an illness or injury for which a benefit has been paid under the Plan. The amount to be reimbursed is the
amount of benefits paid by the Plan.
A “Third Party” means a person or business entity and shall include, but is not limited to, any person or entity
legally responsible for your injury; other benefit plans; an insurance company; any other person or entity that is
obligated to make payments, which the Plan would otherwise be obligated to make.
• The Plan pays benefits for an ineligible individual you had listed as a covered Dependent.
19.02 Subrogation
You or your covered Dependent may, at some time, suer an injury and incur expenses (eligible for coverage under
the Plan) as a result of an accident or act (“Accident”) for which a Third Party is financially responsible. If a Third
Party is responsible for paying any expenses for which the Plan has already issued payment, you automatically assign
the Plan any rights you or your Dependent may have to recover payments from the Third Party—this assignment is
known as “subrogation.” Subrogation allows the Plan to pursue any claim you or your Dependent has against any
Third Party, regardless of whether you or your Dependent chooses to pursue that claim. Examples where subrogation
may be applicable include injuries sustained:
• In an automobile accident caused by someone else; or
• On someone else’s property, if that person is also responsible for causing the injury.
Subrogation does not apply to any expenses that are not eligible for coverage under the Plan (e.g., medical
expenses incurred for injuries or illnesses resulting from any electrical work or any other paid work under Workers’
Compensation).
The Plan may make a claim directly against the Third Party and you and/or your Dependent shall fully cooperate with
the Plan to secure its right to subrogation. If the Plan pays for a claim for you or your Dependent, the Plan has a right
to any amount recovered by you or your Dependent, regardless of whether it is designated as payment for the claim
paid by the Plan, until the Plan is reimbursed in full.
Once the claim or lawsuit arising out of the Accident has been settled or judgment reached, the Plan is not
responsible for the payment of claims related to the Accident that arise or are submitted after the date of settlement
or the entry of the judgment, or that were not timely submitted to the Plan up to the amount of the settlement or
judgment received in connection with the Accident. However, the Trustees, within their discretionary authority, may,
but are under no circumstance obligated, agree in writing prior to the final settlement or resolution of the claim or
legal action that some or all future medical expenses related to the Accident will be covered.
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19.03 Plan’s Priority
When you or your Dependent(s) accept benefits under the Plan, you acknowledge the Plan’s right to reimbursement
and subrogation. The Plan’s right to reimbursement and subrogation will not be reduced or aected as a result of any
fault or claim on the part of you and/or your Dependent, whether under the doctrines of causation, comparative fault
or contributory negligence, or other similar doctrine in law. Therefore, if you and/or your Dependent receive payment
from a Third Party for claims paid by the Plan, you must reimburse the Plan for 100% of the benefits paid under the
Plan. The proceeds from the settlement or judgment must be divided as follows:
• First, the Plan has priority over all monies recovered. Accordingly, you or your representative must pay a sum
sucient to fully reimburse the Plan for 100% of benefits paid related to the injury or illness. You must pay
your own legal fees and costs of litigation in connection with the recovery from a Third Party. No reductions or
deductions from the reimbursement owed to the Plan are allowed for litigation costs, court costs, or attorney’s
fees (i.e., the Illinois Common Fund Doctrine, Make Whole Doctrine, and/or any other state law aecting these
rights are preempted by the Plan under ERISA); then
• Any remainder may be paid to you and/or your Dependent.
The proceeds of any claim against a Third Party must be divided as stated above, even if you and/or your Dependent
are not fully compensated for the loss. The Plan is not entitled to receive reimbursement more than the amount you
and/or your Dependent receive from all third parties.
19.04 Failure to Reimburse the Plan
If you and/or your Dependent receive payment from a Third Party for Plan benefits already received and you do not
reimburse the Plan for 100% of the benefits paid under the Plan (thereby resulting in an “overpayment” by the Plan),
the Plan may take actions, including but not limited to any of the following (separately or in the alternative):
• Initiating a claim to compel compliance with the terms of the Plan and/or the terms of the Subrogation Agreement
and Reimbursement Agreement.
• Suspension or withholding of benefits payable to you and/or your Dependents until you demonstrate that you
have incurred future medical, dental, vision and prescription drug expenses that equal the overpayment had
the expenses been covered by the Plan. The Fund Oce will base reimbursement on 80% of Billed Charges for
proven medical expenses that would have otherwise been covered under the Plan. Any recoupment obtainable
through a vision claim will be based on the applicable out-of-network reimbursement oered by our vision care
provider. The reimbursement rate for expenses that the Fund Oce would have otherwise been the secondary
payer will be based accordingly on standard Coordination for Benefits practices.
• Osetting unpaid reimbursements by any future benefits payable under the Plan, including without limitation for
Short-Term Disability, Long-Term Disability Benefits and Supplemental Unemployment Benefits.
Upon 100% reimbursement to the Plan, future claims related to the injury or illness not already paid by the Plan will
be your and/or your Dependent’s responsibility, unless and until you and/or your Dependents incur related expenses
which exceed the proceeds from your and/or your Dependent’s ultimate recovery.
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19.05 Your Responsibilities
By accepting benefits under the Plan, you and your Dependent’s responsibilities include, but are not limited to, the
following:
• You and/or your Dependent must immediately notify the Fund Oce whenever a claim against a Third Party is
made for yourself and/or your Dependent regarding any loss for which benefits are received from the Plan.
• You and/or your Dependent must timely cooperate with the Plan by providing, among other things, information
requested by the Plan concerning reimbursement or subrogation. You must timely provide the Fund Oce with
a signed Reimbursement Agreement or Subrogation Agreement, with a completed Questionnaire, any accident
reports and any other information the Fund Oce requests.
If you fail to meet your responsibilities, the Plan may suspend or withhold future benefits from you and/or your
Dependents (as described in Section 19.04) until you comply with these requirements.
19.06 Claims for Attorney’s Fees Against the Plan
By accepting benefits under the Plan, you and your Dependent agree to be wholly responsible for all attorney’s fees
or other expenses incurred to obtain the Third-Party recovery.
If the attorney(s) that you and/or your Dependent retain in relation to the Third Party action brings a separate claim or
lawsuit against the Plan to recover his/her attorney’s fees under the Common Fund Doctrine, quantum meruit, unjust
enrichment or other similar state laws, you and/or your Dependent are required to reimburse the Plan from the money
you and/or your Dependent recover from any Third Party for the following:
• Any money judgment entered against the Plan in the lawsuit brought by the attorney; and
• The Plan’s attorney’s fees and costs defending the lawsuit, regardless of whether the Plan prevails or loses.
If the Plan is required to initiate a formal proceeding against you and/or your Dependent(s) to enforce its
reimbursement rights, you and/or your Dependent(s) will be responsible for the Plan’s attorney’s fees and costs
incurred. If the expenses, including attorney’s fees and costs, expended by the Plan exceed the amount you and/
or your Dependent recover from any Third Party and you and/or your Dependent do not reimburse the Plan from
the Third Party recovery, the Plan has the right to withhold benefits to you and/or your Dependent until the Plan is
reimbursed in full for all expenses, including attorney’s fees and costs.
You and/or your Dependent(s) grant the Plan a lien on the monies recovered from any Third Party in the amount of the
following:
• All claims paid on you and/or your Dependent’s behalf relating to the accident, illness or injury for which a Third
Party is financially responsible.
• Any money judgment against the Plan in the lawsuit brought by the attorney.
• The Plan’s attorney’s fees and costs in defending the lawsuit, regardless of whether the Plan prevails or loses.
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SECTION 20: FRAUDULENT CONDUCT BENEFIT
POLICY
20.01 General Provisions
A Participant who acts with the intent to defraud the Plan, including, but not limited to, acts of deception, forgery,
false representation, or concealment of material facts, will be considered in violation of this Policy.
These wrongful acts result in a loss and harm to the Plan. Below is a general list of types of wrongful acts and
general guidelines on the corresponding consequences of such acts. The Fund Oce will assist the Trustees (or their
delegate) in reviewing the circumstances of each wrongful act, calculate the approximate amount of financial harm/
loss caused to the Plan and notify the Participant in writing of its findings under this Policy. Any Participant that is
determined to be in violation of this Policy shall have his or her and his or her Dependent’s benefits otherwise payable
by the Plan oset by the amount listed below to the extent oset is available, or the Trustees could terminate the
individual’s eligibility under the Plan, including retroactively.
The Fund shall determine the amount and manner of the oset, taking into account the gravity of the wrongful act
and harm/loss caused to the Plan. The Fund’s determination of a Participant’s violation of this Policy is an Adverse
Benefit Determination and subject to the Plan’s claims and appeals procedures.
A Participant that cooperates with the Fund in discovering and remedying wrongful acts under this Policy may reduce
or eliminate any potential oset of benefits associated with his or her wrongful acts.
20.02 Possible Offenses and Associated Harm or Loss to the Plan
• Participant is acquiescent or complicit in a contributing employer’s acts to defraud the Plan.
– Benefits otherwise payable by the Plan will be oset by a maximum of $1,000.
• Participant instigates actions to defraud the Plan.
– Benefits otherwise payable by the Plan will be oset by a maximum of $2,500.
• Participant is an owner of and/or exercises control over the contributing employer and under-reports hours
worked thereby diminishing the required contributions to the Plan.
– Benefits otherwise payable by the Plan will be oset by a maximum of $5,000.
• Participant is an owner of and/or exercises control over the contributing employer and engages in wrongful acts
that cause significant harm/loss to the Plan.
– Benefits otherwise payable by the Plan will be oset by a maximum of $7,500, and the Participant will not be
eligible for Retiree Benefits under the Plan.
• Participant enrolls or maintains enrollment of an ineligible dependent.
– Coverage for the ineligible dependent will be terminated retroactive to the date eligibility was lost or to the date
of initial enrollment, to the extent permitted by the Aordable Care Act.
The Trustees reserve the right to terminate an individual’s eligibility under the Plan, including retroactively to the
extent consistent with Aordable Care Act rules, in any instance of wrongful act.
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SECTION 21: CLAIMS AND APPEALS PROCEDURES
21.01 General Provisions
In all circumstances relating to any claim or appeal for benefits under the Plan, the Plan Administrator or claims
administrator responsible for making a determination on the claim or appeal will have discretionary authority in
making the determination, including but not limited to, interpreting and applying the terms and conditions of the Plan,
making any necessary factual determinations and determining eligibility under the Plan. Benefits under the Plan
will be paid only when the Trustees, or persons delegated by them to make such decisions, decide in their sole and
unrestricted discretion, that the participant or beneficiary is entitled to benefits under the terms of the Plan.
You must exhaust all the claims and appeals procedures of the Plan before you bring any action in court or
administrative action for benefits. After you have exhausted all the procedures in this section and if you are
dissatisfied with the written decision of the Board of Trustees on review, you may institute legal action. If you institute
legal action after the denial of your internal appeal or after the denial of your external review, your lawsuit must be
filed within twelve (12) months of the date of the internal appeal denial.
21.02 Definition of a Claim
The following special definitions apply to the Claims and Appeals Procedures described in this section:
A claim or a claim for benefits is a request for Plan benefits that you make in accordance with the Plan’s claim
procedures. If you make an inquiry about the Plan’s provisions without a claim form, the Plan will not treat the
inquiry as a claim for benefits. In addition, if you request prior authorization for a benefit that does not require prior
authorization by the Plan, it will not be treated as a claim for benefits.
A health claim may fall into one of the following categories:
• A pre-service claim is a claim for prior authorization for a treatment or supply that requires approval in advance
of obtaining care. Casual inquiries about benefits or the circumstances under which benefits might be paid are
not considered pre-service claims.
• An urgent care claim is a pre-service claim where the application of time periods for making non-urgent care
determinations could seriously jeopardize the claimant’s life, health or ability to regain maximum function, in
the opinion of a Physician with knowledge of the claimant’s medical condition, or would subject the claimant to
severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
• A post-service claim is a claim for payment that is requested for a treatment or supply that has already been
received.
• A concurrent care claim is a claim where a request is made to extend a course of treatment beyond the period
or number of treatments previously approved. A concurrent care claim can be either an urgent care claim,
a pre-service claim or a post-service claim.
A denial or adverse claim decision is an Adverse Benefit Determination.
A disability claim is a claim for Short-Term Disability benefits, Long-Term Disability benefits or Maternity Leave
benefits.
A health claim is a claim for medical benefits, including behavioral health, substance abuse, hearing aid benefits;
dental benefits; vision benefits; prescription drug benefits; and HRA benefits.
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A document, record or other information is relevant if:
• It was relied upon by the Claim Administrator in making the decision;
• It was submitted, considered or generated in the course of making the decision (regardless of whether it was
relied upon);
• It demonstrates compliance with the Claim Administrator’s administrative processes for ensuring consistent
decision-making; or
• For purposes of a health claim or disability claim, it constitutes a statement of Plan policy regarding the denied
treatment or service.
21.03 Initial Claim Filing Deadline
You must generally file your claims for benefits within 365 days of the date they are incurred, or payment will be
denied. Refer to the Claim Administrator summary below for specific claim filing deadlines that may apply.
You may file claims for Plan benefits and appeal adverse claim decisions, either yourself or through an authorized
representative. If your claim is denied in whole or in part, you will receive a written notice of the denial. The notice will
explain the reason for the denial and the review procedures.
An “authorized representative” means a person you authorize, in writing, to act on your behalf. The Plan will also
recognize a court order giving a person authority to submit claims on your behalf, except that in the case of a claim
involving urgent care, a health care professional with knowledge of your condition may always act as your authorized
representative.
21.04 How to File a Claim
The section below outlines the appropriate claims administrator for each benefit under the Plan and provides
telephone contact information.
Medical Claims
The claims administrator for medical benefits is Blue Cross/Blue Shield of Illinois (BCBS). Network Providers will
submit a claim directly to BCBS on your behalf. However, if you need to submit the claim, call BCBS at (800) 862-
3386 for a Request for Benefit Payment form. Complete the form and attach the bills that explain your treatment.
Submit your claim forms to the address listed on the back of your BCBS card. All paper medical claims should be
submitted to:
Blue Cross/Blue Shield of Illinois
P.O. Box 660603
Dallas TX 75266-0603
When you submit your Request for Benefit Payment form, it should be completed fully, following the instructions
printed on the form. Failure to do so may delay payment or result in a denial of benefits. Attach a statement from your
Physician, or other health care provider, together with bills or receipts for all covered expenses, including those that
count toward the Deductible. To make sure you receive all the benefits you are entitled to, you should keep copies of
bills or receipts for supplies, as well as those for hospitalization and treatment. If all charges are not detailed on the
request form, attach an itemized statement.
If a person entitled to benefits is unable to complete a Request for Benefit Payment form, the Trustees may pay
benefits to the spouse or a blood relative, or to any person whom the Trustees determine is rightfully entitled to the
payment.
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Behavioral Health and Substance Abuse Claims
The claims administrator for behavioral health and substance abuse benefits is Blue Cross/Blue Shield of Illinois
(BCBS). Network Providers will file a claim on your behalf. Non-Network Providers may file a claim for you, but if you
are required to file a claim for behavioral health and substance abuse, call BCBS at (800) 851-7498 to obtain a claim
form. All Non-Network behavioral health and substance abuse claims should be submitted to:
Blue Cross/Blue Shield of Illinois
P.O. Box 660603
Dallas TX 75266-0603
Hearing Aid Claims
The claims administrator for the hearing aid benefit is Blue Cross/Blue Shield of Illinois (BCBS). Network Providers
will file a claim on your behalf. Non-Network Providers may file a claim for you, but if you are required to file a hearing
aid claim, call BCBS at (800) 862-3386 to obtain a hearing aid claim form. All Non-Network hearing aid claims should
be submitted to:
Blue Cross/Blue Shield of Illinois
P.O. Box 660603
Dallas TX 75266-0603
Dental Claims
The claims administrator for dental claims is Blue Cross/Blue Shield of Illinois (BCBS). Network Providers will file a
claim on your behalf. Non-Network Providers may file a claim for you, but if you are required to file a dental claim, call
BCBS at (800) 862-3386 to obtain a dental claim form. All Non-Network dental claims should be submitted to:
Blue Cross/Blue Shield of Illinois
c/o DNoA
P.O. 6 60247
Dallas TX 75266-0247
When you submit your dental claim form, it should be completed fully, following the instructions printed on the form.
Failure to do so may delay payment or result in a denial of benefits. Attach a statement from your Physician or Dentist
together with bills or receipts for all covered expenses, including those that count toward the Deductible. To make
sure you receive all the benefits you are entitled to, you should keep copies of bills or receipts for supplies, as well
as those for hospitalization and treatment. If all charges are not detailed on the request form, attach an itemized
statement.
Prescription Drug Claims
The claims administrator for the prescription drug benefit is CVS/Caremark. If you do not have your prescription drug
card when you make a retail purchase, you must pay for the prescription when purchased and have the pharmacist fill
out a CVS/Caremark claim form. You must then submit your claim to:
CVS/Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136
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Vision Claims
The claims administrator for vision benefits is VSP. All claims from a Network Provider are filed directly with VSP by
the provider.
To submit a claim from a Non-Network Provider, you must contact VSP at (800) 877-7195 to obtain a claim form. The
reimbursement rate is significantly less than it would be if you used a VSP provider.
Important Note!
If you see a Non-Network Provider for vision benefits, you must file your claim(s), and the filing limit is six months from the
date of service.
Short-Term and Long-Term Disability Claims
To collect Short-Term Disability or Long-Term Disability benefits, you must contact the Fund Oce and obtain a
claim form. To be eligible for disability benefits, time limits apply for when notice must be provided to the Fund Oce.
See Section 12 for more information.
The Fund Oce will send a claim form to you. It must be completed by you, your employer and your Physician and
returned to the Fund Oce. You also must supply the Fund Oce with information the Trustees require (i.e., proof of
your claim).
The Fund Oce will forward your completed claim form to a third-party case management service for medical review
before any benefits are paid. All benefits are subject to certification by the case management service.
If the Fund Oce determines that you received Short-Term Disability or Long-Term Disability benefits to which you
were not entitled, you will be required to reimburse the Fund for any benefit payments made to you.
Your proof of claim must show the following:
• That you are under the regular care of a licensed Physician or behavioral health provider;
• The date your disability began;
• The cause of your disability;
• The extent of your disability — including restrictions and limitations preventing you from performing
your regular job; and
• The name and address of any Hospital or facility where you received treatment, as well as all attending
Physicians.
The Plan reserves the right to request an independent medical exam by a selected Physician to review your
eligibility for disability benefits.
Maternity Leave Claims
To collect Maternity Leave Benefits, you must contact the Fund Oce and obtain a maternity leave statement.
It must be completed by you and your doctor and returned to the Fund Oce. The completed statement must
be filed with the Fund Oce no later than 90 days after your due date or delivery date, whichever is later. You
must also supply the Fund Oce with any other information the Trustees require to process your claim for
Maternity Leave Benefits.
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Basic Life Insurance and AD&D Claims
To collect the Basic Life Insurance Benefit, your Designated Beneficiary must advise the Fund Oce of your death
and obtain a claim form. The completed claim form must be filed with the Fund Oce within 91 days of the date of
your death. Your Designated Beneficiary must supply the Fund Oce with information the Trustees require.
To receive AD&D Benefits, you or your Designated Beneficiary must contact the Fund Oce and obtain a claim form.
The completed claim form must be filed with the Fund Oce within 91 days of the date of your accident or death. You
or your Designated Beneficiary must supply the Fund Oce with information the Trustees require.
All Other Claims
For any other claim, you must contact the Fund Oce and obtain a claim form.
21.05 Claims Processing Timeframes
The Plan has a specific amount of time, by law, to evaluate and respond to claims for benefits covered by ERISA. The
period the Plan must evaluate and respond to a claim begins on the date the claim is first filed with the applicable
claims’ administrator, regardless of whether the Plan has all the information necessary to decide the claim. The
amount of time the Plan can take to process a claim depends on the type of claim.
Pre-Service Claims
BCBS will notify you of the decision on your claim within 15 days from receipt of the claim. BCBS may extend this
period one-time for up to 15 days if the extension is necessary due to matters beyond its control. If an extension
is necessary, BCBS will notify you before the end of the initial 15-day period of the circumstances requiring the
extension of time and the date by which BCBS expects to render a decision.
If an extension is needed because BCBS needs additional information from you to process your claim, the extension
notice will specify the information needed. In that case you will have 45 days from the time you receive the
notification to supply additional information. If you do not provide the information within that time, your claim will be
decided on the basis of the information that BCBS has at the time and your claim may be denied. During the period in
which you are allowed to supply additional information, the normal period for making a decision on the claim will be
suspended. The deadline is suspended from the date of the extension notice until the earlier of 1) 45 days, or 2) the
date you respond to the request. BCBS then has 15 days to make a decision and notify you of the determination.
Urgent Care Claims
BCBS will notify you of the decision on your claim within 72 hours of BCBS’s receipt of the claim.
If an extension is needed because BCBS needs additional information from you to process your claim, BCBS will
notify you of such an extension within 24 hours. In that case you will have 48 hours from the time you receive the
notification to supply the additional information. If you do not provide the information within that time, your claim will
be decided based on the information that BCBS has at the time and your claim may be denied. During the period in
which you are allowed to supply additional information, the normal period for making a decision on the claim will be
suspended. The deadline is suspended from the date of the extension notice until the earlier of either 48 hours or
until you respond to the request. BCBS then has 48 hours to make a decision and notify you of the determination.
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Concurrent Care Claims
If the concurrent care claim is urgent and made 24 hours prior to the end of the already authorized treatment,
BCBS will notify you of its decision within 24 hours. If the concurrent care claim is not an urgent claim, then it will be
decided according to the pre-service or post service claim time frames, whichever applies.
Post-Service Claims
BCBS will notify you of the decision on your claim within 30 days of BCBS’ receipt of the claim. BCBS may extend
this period one time for up to 15 days if the extension is necessary due to matters beyond the control of BCBS. If an
extension is necessary, BCBS will notify you before the end of the initial 30-day period of the circumstances requiring
the extension of time and the date by which BCBS expects to render a decision.
If an extension is needed because BCBS needs additional information from you to process your claim, the extension
notice will specify the information needed. In that case, you will have 45 days from the time you receive the
notification to supply the additional information. If you do not provide the information within that time, your claim will
be decided based on the information that BCBS has at that time and your claim may be denied. During the period in
which you are allowed to supply additional information, the normal period for making a decision on the claim will be
suspended. The deadline is suspended from the date of the extension notice until the earlier of either 45 days or until
the date you respond to the request (whichever is earlier). BCBS then has 15 days to make a decision and notify you
of the determination.
Disability Claims
The Plan will make a decision on your Short-Term Disability, Long-Term Disability or Maternity Leave Benefit claim
and notify you of the decision within 45 days. If the Plan requires an extension of time due to matters beyond the
control of the Plan, the Plan will notify you (within the 45-day period) of the reason for the delay and the time when
the decision will be made. The Plan will make its decision within 30 days of the time the Plan notifies you of the delay.
If the 30-day extension is not sucient, the Plan may delay the period for making a decision for an additional 30 days,
provided the Plan notifies you of the circumstances requiring the extension and the date as of which the Plan expects
to render a decision, before the expiration of the first 30-day extension period.
If an extension is needed because the Plan needs additional information from you to process your claim, the
extension notice will specify the information needed. In that case, you will have 45 days from the time you receive the
notification to supply the additional information. If you do not provide the information within that time, your claim will
be decided based on the information that the Plan has at that time and your claim may be denied. During the period
in which you are allowed to supply additional information, the normal period for making a decision on the claim will be
suspended. The deadline is suspended from the date of the extension notice until the earlier of either 45 days or until
the date you respond to the request (whichever is earlier). Once the Plan has received a response to its request, the
Plan has 30 days to make a decision and notify you of the determination.
Life and Accidental Death and Dismemberment Claims
The Claim Administrator will notify you of the decision on your claim within 90 days of receipt of the claim. The Claim
Administrator may extend this period one time for up to 90 days if an extension is necessary due to matters beyond
the control of the Claim Administrator. If an extension is necessary, the Claim Administrator will notify you before the
end of the initial 90-day period of the circumstances requiring the extension of time and the date by which the Plan
expects to render a decision.
If you have any questions regarding how to file or appeal a claim, contact the Fund Oce.
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21.06 Notice of Initial Decision
If your claim is denied, in whole or in part, you will receive a written explanation of the Adverse Benefit Determination,
in a culturally and linguistically appropriate manner, within certain timeframes after your claim is received. The
information included in this written notice varies depending on the type of claim. All notices will include:
• The specific reason(s) for the denial of benefits or other Adverse Benefit Determination;
• A specific reference(s) to the Plan provisions on which the denial is based;
• If applicable, a description of any additional information that is needed to process your claim and the reason the
information is needed; and
• A copy of the internal review procedures and time periods to appeal your claim, and a statement of your right to
bring a civil action lawsuit under ERISA section 502(a) following a denial of your claim on review.
If the claim was for a health benefit, the written explanation will also include:
• If an internal rule, guideline, protocol or similar criteria was relied on in the process of making a decision on your
claim, a copy of that internal rule, guideline, protocol, or similar criteria, or a statement that a copy is available to
you at no cost upon request; and
• If your claim was denied based on Medical Necessity, Experimental or Investigational Treatment, or a similar
exclusion or limit, a copy of the scientific or clinical judgment that was relied on in the process of making a
decision on your claim or a statement that it is available to you at no cost upon request.
If the claim was for a health benefit except for dental or vision benefits, the written explanation will also include:
• Sucient information to identify the claim involved, including the date of service, the health care provider and
the claim amount (if applicable), and a statement that, upon request, the Plan will provide the diagnosis code and
its corresponding meaning, and the treatment code and its corresponding meaning;
• The denial code and its corresponding meaning;
• A statement of your right to request an external review with an independent review organization following denial
on appeal, including a description of how to initiate an expedited external review, if applicable;
• If applicable, a notice in any applicable non-English language describing how to access the Plan’s language
services; and
• If applicable, the availability of and contact information for any applicable oce of health insurance consumer
assistance or ombudsman to assist individuals with the internal claims and appeals and external review
processes.
If the claim was for a disability benefit, the written explanation will also include:
• Information sucient to identify the claim involved, including the date of service;
• An explanation of the decision, including the basis for disagreeing with or not following, as applicable:
– The views you presented to the Plan of the health care and vocational professionals who treated or
evaluated you;
– The views of medical or vocational experts obtained by the Plan in connection with the Adverse Benefit
Determination, without regard to whether the advice was relied upon in making the adverse benefit
determination; and
– A disability determination by the Social Security Administration.
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• If an internal rule, guideline, protocol, standard or similar criteria was relied on in the process of making a
decision on your claim, a copy of that internal rule, guideline, protocol, or similar criteria, or alternatively, a
statement that such internal rules, guidelines, protocols, standards or other similar criteria do not exist;
• If your claim was denied based on Medical Necessity, Experimental or Investigational Treatment, or a similar
exclusion or limit, a copy of the scientific or clinical judgment that was relied on in the process of making a
decision on your claim or a statement that it is available to you at no cost upon request;
• A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies
of, all documents, records, and other information relevant to the claim for benefits; and
• The timeframe for bringing a civil action under ERISA.
21.07 Appealing the Denial of an Internal Claim
If your claim has been denied, in whole or in part, you may request a full and fair review (referred to in this section
as an “appeal”) by filing a written notice of appeal with the Plan, unless otherwise provided herein. Only one level of
appeal—review by the Claims Review Committee of the Board of Trustees or the Claims Administrator—exists for all
claims except for medical claims, which have two levels of appeal, as detailed below.
You must file your appeal in writing, unless your appeal is an urgent care claim, which may be submitted orally or by
telephone. You must make your request within 180 days after receiving notice of the denial, except with respect to
Basic Life Insurance and AD&D claims.
You must file a request for an appeal of the denial of a Basic Life Insurance or AD&D claim within 60 days after
receiving notice of the denial. Your appeal application must be in writing and it must include the specific reasons
you feel the denial was improper. You may submit any document you feel appropriate, as well as submitting your
written statement.
Besides having the right to appeal, you or your authorized representative can examine any documents, records and
other information relevant to your denied claim. Additionally, for health claims except dental and vision claims and for
disability claims, the Plan or claim administrator will:
• Provide you, free of charge with any new or additional information considered, relied upon or generated during
the appeal as soon as possible and suciently in advance of the date on which the notice of final internal Adverse
Benefit Determination is required to be provided to give you a reasonable opportunity to respond prior to that
date. For health claims only, if the new or additional information is received so late that you would not have a
reasonable opportunity to respond, the period for issuing the final internal Adverse Benefit Determination will
be tolled to provide you with time to respond. The Plan/Claim Administrator will issue its decision as soon as
reasonably practical after you respond or the period you were provided to respond has ended.
• Provide you, free of charge, with any new rationale for denying your claim as soon as possible and suciently in
advance of the Plan’s/claim administrator’s final decision, to give you a reasonable opportunity to respond.
A dierent person will review your appeal than the one who originally denied the claim. The reviewer will not give
deference to the initial Adverse Benefit Determination. You have the right to present evidence and written testimony
as part of your appeal. The decision will be made based on a full and fair review of the record, including such
additional evidence and testimony that you may submit.
If your health claim or disability claim was denied based on a medical judgment (such as a determination that the
treatment or service was not Medically Necessary, or was Experimental or Investigational Treatment), a health care
94
professional who has appropriate training and experience in a relevant field of medicine will be consulted. Upon
request, you will be provided with the identification of medical or vocational experts, if any, who gave advice to the
Plan on your claim, without regard to whether their advice was relied upon in deciding your claim.
Additional procedures for appealing particular claims are outlined below.
Medical Claims
If your claim is denied, in whole or in part, you may appeal the denial. There are two levels of the appeals process, as
described below.
You must submit your first appeal to Blue Cross/Blue Shield of Illinois (BCBS) within 180 days of the date of the BCBS
non-favorable decision. In addition, your provider may opt to perform a peer-to-peer review. A peer-to-peer review
must be requested prior to filing an appeal with BCBS.
If BCBS denies your appeal, you may then request a second level of appeal with the Claims Review Committee within
180 days of the date of the BCBS non-favorable decision.
21.08 Timing of Notice of Decision on Internal Appeal
Urgent Care Claims
If the appeal is for an urgent care claim, you will be notified of the decision on appeal as soon as possible, but not
later than 72 hours after the receipt of the request for appeal.
Concurrent Care Appeals
An appeal of a concurrent care decision to reduce or terminate previously approved benefits may be an urgent care,
pre-service or post-service claim, depending on the facts.
All Non-Urgent Pre-Service Care Claims
If the appeal is for a non-urgent pre-service claim, you will be notified by BCBS no later than 15 days after receipt of
the request for appeal, or 15 days for each level of appeal, if two mandatory appeals are allowed (no extensions).
Post-Service Care Claims
If the appeal is for a post-service claim, you will be notified no later than 30 days after receipt of the request for
appeal, or 30 days for each level of appeal, if two mandatory appeals are allowed (no extensions).
All Other Claims
The Plan will send you a notice of the decision on appeal within 60 days of the receipt of the appeal (up to 60-day
extension).
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21.09 Notice of Decision on Internal Appeal
The Plan/Claim Administrator will provide you with a written decision on any internal appeal of your claim. However,
if your claim is an urgent care claim, the Plan may notify you of the decision in writing, via fax or orally via telephone.
The information included in the notice of a denial of a claim on appeal varies depending on the type of claim. All
notices will state:
• The specific reason(s) for the determination;
• References to the Plan provisions on which the denial is based;
• A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies
of, all documents, records, and other information relevant to the claim for benefits; and
• A statement of your right to bring a civil action under ERISA following an Adverse Benefit Determination on
appeal.
If the appeal was for a health benefit, the notice will also include:
• If an internal rule, guideline or protocol was relied upon, you will receive either a copy of the rule or a statement
that it is available upon request at no charge; and
• If the determination was based on medical necessity or because the treatment was Experimental or
Investigational Treatment or other similar exclusion, the Plan will provide you with an explanation of the scientific
or clinical judgment for the determination applying the terms of the Plan to your claim, or a statement that it is
available upon request at no charge.
If the appeal was for a health benefit except for dental or vision benefits, the notice will also include:
• Sucient information to identify the claim involved, including the date of service, the health care Provider and
the claim amount (if applicable). Upon request, the Plan will provide the diagnosis code and its corresponding
meaning, and the treatment code and its corresponding meaning;
• An explanation of the Plan’s/claim administrator’s decision;
• For claims involving medical judgment or the balance billing protections of the No Surprises Act, a statement of
your external appeal rights, an explanation regarding how to initiate those rights;
• If applicable, the availability of and contact information for any applicable oce of health insurance consumer
assistance or ombudsman to assist individuals with the internal claims and appeals and external review
processes; and
• If applicable, a notice in any applicable non-English language describing how to access the Plan’s language
services.
If the appeal was for a disability benefit, the written explanation will also include:
• Sucient information to identify the claim involved, including the date of service;
• A discussion of the decision, including an explanation for disagreeing with or not following, as applicable:
– The views you presented to the Plan of the health care and vocational professionals who treated or
evaluated you;
– The views of medical or vocational experts obtained by the Plan in connection with the Adverse Benefit
Determination, without regard to whether the advice was relied upon in making the adverse benefit
determination; and
– A disability determination made by the Social Security Administration regarding you and presented to the Plan.
96
• If an internal rule, guideline, protocol, standard or similar criteria was relied on in the process of making a
decision on your claim, a copy of that internal rule, guideline, protocol, or similar criteria, or alternatively, a
statement that such internal rules, guidelines, protocols, standards or other similar criteria do not exist;
• If the determination was based on medical necessity or because the treatment was Experimental or
Investigational Treatment or other similar exclusion, the Plan will provide you with an explanation of the scientific
or clinical judgment for the determination applying the terms of the Plan to your claim, or a statement that it is
available upon request at no charge; and
• A description of any contractual limitations period that applies to your right to bring a civil action under ERISA
following an Adverse Benefit Determination on appeal, including the calendar date on which the Plan’s 90-day
limit for filing suit expires.
21.10 External Appeal Process
External Review Filing Deadline
If your health care claim except dental and vision claims involved medical judgment, rescission of coverage, or
compliance with cost-sharing and surprise billing protections under the No Surprises Act and was denied, resulting in
an Adverse Benefit Determination, you have the right to file a request for an external review by an independent review
organization (“IRO”) with the Fund Oce within four months of the date of the appeal decision.
However, you do not have a right to request external review if your health care claim did not involve medical
judgment, a rescission of coverage or compliance with cost-sharing and surprise billing protections under the No
Surprises Act. For example, a denial, reduction, termination, or a failure to provide payment for a benefit based on a
determination that you or your Dependent fails to meet the requirements for eligibility under the terms of the Plan is
not eligible for the external review process.
Dental claims, vision claims, disability claims and Basic Life and AD&D claims are also not eligible for external review.
External Review Process
The external review process works as follows:
• Request for External Review
Within five days of the Plan’s receipt of your written request for external review, the Plan must determine whether:
– You are or were covered under the Plan at the time of service or requested service;
– The Adverse Benefit Determination does not relate to your failure to meet the Plan’s eligibility requirements;
and
– You have provided all information and forms required to process an external review.
• Determination of Eligibility for External Review
Within one business day after the completion of this review, the Plan must notify you (or your authorized
representative) whether the request is complete and is eligible for external review. If the request is not complete,
the Plan must provide notice of what information or materials are needed and allow you to perfect the request
within the four-month filing period or 48 hours following receipt of the notification, whichever is later. If the
request is not eligible for external review, the notice must include the reason(s) for ineligibility and contact
information for the Employee Benefits Security Administration.
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• Referral to an Independent Review Organization (IRO)
If your request is eligible for external review, the Plan will utilize an unbiased method to assign the external
review to an IRO. An IRO is a third party accredited by URAC (or other similar nationally-recognized accrediting
organization) to conduct external review of benefit claims. The IRO is not eligible for any financial incentives
based on the likelihood that it will deny a claim. The Plan will contract with IROs and will rotate claim assignments
among them in accordance with applicable law. The timeline for completion of the external review is as follows:
– The IRO will timely notify you of receipt of the assignment of the external review and such notice will inform you
that you may provide additional information within ten business days following receipt of the notice. The IRO is
not required, but may, accept and consider additional information submitted after ten business days.
– The Plan must provide the claim file and any information considered in making the Adverse Benefit
Determination within five business days after the date of assignment to the IRO. Failure by the Plan to submit
the information to the IRO may result in an immediate reversal of the Adverse Benefit Determination. The IRO
must send notice of such to you and the Plan within one business day.
– The IRO must forward any additional information received from you to the Plan within one day of receipt and
the Plan may reconsider and reverse its decision, terminating the external review. The Plan must provide notice
within one business day of such a decision to you and the IRO.
– The IRO will review all information received de novo. In addition to all information provided, the IRO may
consider the following information, if the IRO deems it appropriate:
⚬ The claimant’s medical records;
⚬ The attending health care professional’s recommendation;
⚬ Reports from appropriate health care professionals and other documents submitted by the Plan, claimant or
treating provider;
⚬ The terms of the Plan;
⚬ Appropriate practice guidelines, which must include all evidence-based standards and may include any other
practice guidelines developed by the federal government, national or professional medical societies, boards
and associations;
⚬ Any applicable clinical review criteria developed and used by the Plan, unless the criteria is inconsistent with
the terms of the Plan or applicable law; and
⚬ The opinion of the IRO’s clinical reviewer or reviewers after considering the information described in this
notice to the extent the information or documents are available, and the clinical reviewer or reviewers
consider it appropriate.
Request for an Expedited External Review
You may make a request for an expedited external review if the Adverse Benefit Determination involves a medical
condition for which the timeframe for completion of an expedited internal appeal or standard external review as
described above would seriously jeopardize the life or health of the claimant or would jeopardize the ability to regain
maximum function or if the final Adverse Benefit Determination concerns an admission, availability of care, continued
stay, or health care item or service for which the claimant received Emergency Services, but has not been discharged
from a facility.
An expedited external review will occur in accordance with the procedures stated above for a standard external
review, except that each step must be performed in the most expeditious method and the IRO must provide the
98
claimant notice of its decision as expeditiously as the circumstances require, but no more than 72 hours after the IRO
receives the request for an expedited external review. If the decision is not communicated in writing, the notice must
provide written confirmation to you and the Plan within 48 hours after notice is provided.
Timing of Notice of Decision on External Review
The assigned IRO must provide written notice of the final external review to the claimant and the Plan within 45 days
after the IRO first receives the request for review.
Content of Notice of Decision on External Review
The IRO will provide you and the Plan with a written decision. The notice of the decision will contain all the following:
• A general description of the reason for the request for external review including sucient information to identify
the claim involved, including the date of service, the health care Provider, the claim amount (if applicable), the
diagnosis code and its corresponding meaning, the treatment code and its corresponding meaning and the
reason for the previous denial.
• The date the IRO received the assignment and the date of the IRO decision.
• Reference to the evidence or documentation, including the specific coverage provisions and evidence-based
standards that were relied on in making its decision.
• A discussion of the principal reason(s) for the IRO’s decision, including the rationale for the decision and any
evidence-based standards that were relied on in making its decision.
• A statement that the determination is binding except to the extent that other remedies may be available under
state or federal law to either the Plan or the claimant.
• A statement that judicial review may be available to the claimant.
• Current contact information, including phone numbers, for any applicable oce of health insurance consumer
assistance or ombudsmen established under PHS Act section 2793.
21.11 Physical Examination
The Trustees have the right and opportunity, at the Plan’s expense, to have a Physician they designate examine you or
your Dependent as often as is reasonable while your claim for Plan benefits is pending.
21.12 Authorized Representatives
An authorized representative, such as your spouse, may complete the claim form for you if you are unable to
complete it yourself and have previously designated the authorized representative to act on your behalf. You may
obtain a form from the Fund to designate an authorized representative.
The Fund may request additional information to verify that this person is authorized to act on your behalf. The Fund
reserves the right to withhold information from a person who claims to be the authorized representative, if there is
suspicion about the qualifications of the individual claiming to be the authorized representative.
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21.13 Benefit Payment to an Incompetent Person
Benefit payments under the Plan may become payable to a person who is adjudicated incompetent or to a person
who, by reason of mental or physical disability, in the opinion of the Trustees, is unable to administer such payments
properly. In that event, the Trustees may make payments for the benefit of the incompetent person as they deem
best. The Trustees will have no right or obligation to see that the funds are used or applied for the purpose(s) for
which if they are paid:
• Directly to such person;
• To the legally appointed guardian or conservator of such person;
• To any spouse, child, parent, brother or sister or such person for the welfare, support and maintenance of that
person; or
• By the Trustees directly for the support, maintenance and welfare of such person.
If any question or dispute arises concerning the proper person or persons to whom any payment will be made under
the Fund, the Trustees may withhold payment until a binding adjudication of the question or dispute is made. The
resolution must be satisfactory to the Trustees in their sole discretion. Alternatively, the Trustees may pay the benefits
if they have been adequately indemnified to their satisfaction against any resulting loss.
21.14 Misrepresentation or Falsification by Participant
If you make an intentional misrepresentation or falsification of any information or a matter in connection with any
application or claim for benefits, the Trustees or their representative(s) may deny all of part of the benefits that might
otherwise be due.
21.15 Prohibition of Rescission
The Fund cannot rescind coverage except in the case of fraud or an intentional misrepresentation of a material fact.
A rescission is a cancellation or discontinuance of coverage initiated by the Fund that has retroactive eect, unless
it is attributable to a failure to pay timely required premiums or contributions towards the cost of coverage. The Fund
must provide thirty (30) calendar days advance notice to a covered person before coverage may be rescinded.
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SECTION 22: YOUR ERISA RIGHTS
As a participant in the EIT Health and Welfare Plan for Construction Workers, you are entitled to certain rights and
protections under the Employee Retirement Income Security Act of 1974, as amended (ERISA).
Although ERISA does not require an employer to provide benefits, it does set standards on how a Plan is run. It
also requires that you be kept fully informed of your rights and benefits — the details of which are included in this
Summary Plan Description (SPD)/Plan.
ERISA provides that all Plan participants shall be entitled to the following rights.
22.01 Receive Information about Your Plan and Benefits
You may examine, free of charge, all documents governing the Plan including insurance contracts, collective
bargaining agreements and the latest annual report (Form 5500 Series). These documents are available at the Plan
Administrator’s oce and at other specified locations. The annual report is also filed with the U.S. Department of
Labor and is available at the Public Disclosure Room of the Employee Benefits Security Administration.
You may obtain, upon written request to the Plan Administrator, copies of all documents governing the operation of
the Plan, including insurance contracts, collective bargaining agreements, and copies of the latest annual report
(Form 5500 Series), SPD and all Summaries of Material Modifications (SMM). The Plan Administrator may make a
reasonable charge for the copies.
You may also receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to
furnish each participant with a copy of this summary annual report.
22.02 Continuing Group Health Plan Coverage
Under COBRA, you may continue health care coverage for yourself, your spouse or your Dependents if there is a
loss of coverage under the Plan as a result of a Qualifying Event. However, you or your Dependents may have to pay
for such coverage. Review this SPD/Plan and the documents governing the Plan for the rules governing your COBRA
coverage rights.
22.03 Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for
operating the Plan. These people are called “fiduciaries” of the Plan. They have a duty to act prudently and in the
interest of you and other Plan participants and beneficiaries.
No one, including your employer, your Union or any other person, may fire you or otherwise discriminate against you
in any way to prevent you from obtaining a welfare benefit to which you are otherwise entitled or from exercising your
rights under ERISA.
22.04 Enforcement of Your Rights
If your claim for a welfare benefit is denied, in whole or in part, the Plan Administrator must give you a written
explanation of the reason for the denial, and you can obtain copies of documents relating to the decision, without
charge. You also have the right to appeal any denial, all within certain defined time schedules. Please note that you
or any other claimant may not begin any legal action, including proceedings before administrative agencies, until you
have followed and exhausted the Plan’s claims and appeal procedures.
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Under ERISA, there are steps you can take to ensure the above rights. For instance, if you request a copy of the
Plan documents or the latest annual report from the Plan Administrator and do not receive them within 30 days, you
may file suit in a federal court. In such a case, the court may require the Plan administrator to provide the materials
and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons
beyond the control of the Plan Administrator.
If your claim for benefits is denied or ignored, in whole or in part, you may file suit in a state or federal court. You may
also file suit in a federal court if you disagree with a decision, or the lack of a decision concerning the qualified status
of a medical child support order. If Plan fiduciaries misuse the Plan’s money or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal
court.
The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person
you have sued to pay these costs and fees. If you lose (for example, if the court finds your claim is frivolous), it may
order you to pay these costs and fees.
22.05 Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about
this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan
Administrator, you should contact the nearest oce of the Employee Benefits Security Administration (EBSA), U.S.
Department of Labor, listed in your telephone directory or contact the:
Division of Technical Assistance and Inquiries
Employee Benefits Security Administration
U.S. Department of Labor
200 Constitution Avenue N.W.
Washington, D.C. 20210
You may also find answers to your Plan questions, your rights and responsibilities under ERISA and a list of EBSA filed
oces by contacting the EBSA:
• By calling (866) 444-3272;
• Sending electronic inquiries to www.askebsa.dol.gov; or
• Visiting the ESBA website at www.dol.gov/ebsa.
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SECTION 23: YOUR HIPAA RIGHTS
23.01 Privacy Policy
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health plans protect the
confidentiality of your private health information. A complete description of your rights under HIPAA can be found in
the Plan’s privacy notice. The privacy notice will be available from the Plan Administrator.
The Plan and the Plan Sponsor will not use or further disclose information that is protected by HIPAA (“protected
health information”), except as necessary for treatment, payment, health plan operations and plan administration, or
as permitted or required by law. In particular, the Plan will not, without authorization, use or disclose protected health
information for employment-related actions and decisions or in connection with any other benefit or employee benefit
plan. The Plan also hires professionals and other companies to assist it in providing health care benefits. The Plan will
require all of its business associates to also observe HIPAA’s privacy rules.
Under HIPAA, you have certain rights with respect to your protected health information, including certain rights to
see and copy the information, receive an accounting of certain disclosures of the information and, under certain
circumstances, amend the information. You will also have the right to file a complaint with the Plan or with the
Secretary of the U.S. Department of Health and Human Services if you believe your rights under HIPAA have
been violated.
The Plan maintains a privacy notice that provides a complete description of your rights under HIPAA’s privacy rules.
Please contact the Fund Oce if:
• You need a copy of the Privacy Notice;
• You have questions about the privacy of your health information; or
• You wish to file a complaint under HIPAA.
23.02 Use and Disclosure of Protected Health Information (PHI)
How the Plan Uses and Discloses Your PHI
The Plan will use your protected health information (PHI) to the extent and in accordance with the uses and
disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the
Plan will use and disclose protected health information for purposes related to health care treatment, payment for
health care, and health care operations.
The Plan will use and disclose your PHI as required by law and as permitted by your authorization or the authorization
of your beneficiary. With an authorization, the Plan will disclose PHI to Pension Plan No. 2, Pension Plan No. 5,
reciprocal benefit plans or Workers’ Compensation insurers for purposes related to administration of those plans.
Definition of Payment
Payment includes activities undertaken by the Plan to determine or fulfill its responsibility for coverage and provision
of Plan benefits that relate to an individual to whom health care is provided. These activities include, but are not
limited to, the following:
• Determination of eligibility, coverage and cost sharing amounts (e.g., cost of a benefit, Plan maximums and
copayments as determined for an individual’s claim);
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103
• Coordination of benefits;
• Adjudication of medical benefit claims (including appeals and other payment disputes);
• Subrogation of medical benefit claims;
• Establishing Employer contributions;
• Risk adjusting amounts due based on enrollee health status and demographic characteristics;
• Billing, collection activities and related health care data processing;
• Claims management and related health care data processing, including auditing payments, investigating and
resolving payment disputes and responding to Participant (and their authorized representatives) inquiries
about payments;
• Obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance);
• Medical necessity reviews, or reviews of appropriateness of care or justification of charges;
• Utilization review, including pre-certification, pre-authorization, concurrent review and retrospective review;
• Disclosure to consumer reporting agencies related to collection of premiums or reimbursement (the following
PHI may be disclosed for payment purposes: name and address, date of birth, social security number, payment
history, account number, and name and address of the provider and/or health plan); and
• Reimbursement to the Plan.
Definition of Health Care Operations
Health Care Operations include, but are not limited to, the following activities:
• Quality assessment;
• Population-based activities relating to improving health or reducing health care costs, protocol development,
case management and care coordination, disease management, contacting of health care Providers and patients
with information about treatment alternatives and related functions;
• Rating provider and Plan performance, including accreditation, certification, licensing or credentialing activities;
• Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of
health insurance or medical benefits, and ceding, securing, or placing a contract for reinsurance of risk relating
to claims for health care (including stop-loss insurance and excess of loss insurance);
• Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse
detection and compliance programs;
• Business planning and development, such as conducting cost-management and planning- related analyses
related to managing and operating the entity, including formulary development and administration, development
or improvement of methods of payment or coverage policies; and
• Business management and general administrative activities of the entity, including, but not limited to:
– management activities relating to implementation of and compliance with the requirements of HIPAA
Administrative Simplification;
– customer service, including the provision of data analyses for policyholders, plan sponsors or other customers;
– resolution of internal grievances; and
– due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the
potential successor in interest is a covered entity or following completion of the sale or transfer, will become a
covered entity.
104
The Plan’s Disclosure of PHI to the Board of Trustees
The Board of Trustees is the Plan Sponsor. With respect to PHI, the Plan Sponsor agrees to:
• Not use or further disclose the information other than as permitted or required by this SPD or as required by law;
• Ensure that any agents, including a subcontractor to whom the Plan Sponsor provides PHI received from
the Plan, agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such
information;
• Not use or disclose the information for employment-related actions and decisions unless authorized by the
individual;
• Not use or disclose the information in connection with any other benefit or employee benefit plan of the plan
sponsor unless authorized by the individual;
• Report to the Plan any use or disclosure of the information of which it becomes aware that is inconsistent with the
uses or disclosures provided for in this document;
• Make PHI available to the individual in accordance with the access requirements of HIPAA;
• Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA;
• Make the information available that is required to provide an accounting of disclosures;
• Make internal practices, books and records relating to the use and disclosure of PHI received from the group
health Plan available to the Secretary of HHS for the purposes of determining compliance by the group health
Plan with HIPAA; and
• If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and
retain no copies of such information when no longer needed for the purpose for which disclosure was made. If
return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or
destruction infeasible.
• Adequate separation between the Plan and the Plan Sponsor will be maintained. Therefore, in accordance with
HIPAA, only the following employees or classes of employees will be given access to PHI:
• The Executive Director; and
• Sta designated by the Executive Director.
The persons described above will only have access to and will only use and disclose PHI for Plan administration
functions that the Plan Sponsor performs for the Plan. If these persons do not comply with this SPD, the Plan Sponsor
will provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.
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SECTION 24: IMPORTANT PLAN INFORMATION
24.01 Plan Name
The ocial name of the Plan is the Electrical Insurance Trustees Health and Welfare Plan for Construction Workers.
This combination Plan document and SPD describes the benefits provided under the Plan.
24.02 Board of Trustees
A Board of Trustees is responsible for the administration and operation of the Plan. The Board of Trustees consists
of an equal number of Employer and Union representatives, selected by the employers and the Union, which have
entered into Collective Bargaining Agreements relating to the Plan. If you wish to contact the Board of Trustees, you
may use the addresses below. As of the date of this SPD, the Trustees are as follows:
Employer Trustees
Kenneth J. Bauwens
Jamerson & Bauwens Electrical Contractors, Inc.
3160 MacArthur Blvd
Northbrook, Illinois 60062
(847) 291-2000
Thomas Rivi
G&M Electrical Contractors
1746 N. Richmond Street
Chicago, Illinois 60647
(773) 278-8200
Je Weir
KB Advanced Technologies
200 W. Jackson Blvd, Suite 1200
Chicago, Illinois 60606
(312) 447-5750
David Witz
Continental Electrical Construction Co.
815 Commerce Drive, Ste 100
Oak Brook, Illinois 60523
(630) 288-0222
Union Trustees
Donald Finn
Brian Brown
Jim Conaghan
Kevin Connolly
John P. Dalton, Jr.
2722 S. Martin Luther King Drive
Chicago, Illinois 60616
(312) 454-1340
24.03 Plan Administrator and Sponsor
The Board of Trustees is the Plan Administrator and Plan Sponsor. The Board of Trustees has full authority to
increase, reduce or eliminate benefits and to change all provisions of the Plan at any time and from time to time. The
Plan is maintained for the exclusive benefit of its participants and beneficiaries.
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24.04 Plan Number
The Plan number assigned to the Plan by the Board of Trustees pursuant to instructions of the Internal Revenue Code
is 501.
24.05 Employer Identification Number
The employer identification number assigned to the Board of Trustees by the Internal Revenue Service is 36-
1033970.
24.06 Plan Year
The Plan year begins on July 1 and ends on the following June 30.
24.07 Amendment and Termination of the Plan
Although the Trustees intend to continue the Plan indefinitely, the Trustees have the authority and unconditionally
reserve the right, in their sole and unrestricted discretion, to change, amend or end the Plan at any time, or from time
to time, for any reason. You do not earn a vested right to health benefits.
Changes may be made retroactively, if necessary, to qualify or maintain the benefits under the Internal Revenue Code
or ERISA. If the Plan is amended or ends, you may not receive benefits as described in this SPD. However, you may be
entitled to receive dierent benefits, or benefits under dierent conditions or no additional benefits.
24.08 Plan Funding
The benefits described in this SPD are provided through contributions and self-payments. The amount of Employer
contributions and the Employees on whose behalf contributions are made are determined by the provisions in the
applicable Collective Bargaining Agreements and other participation agreements. The amount of self-payments are
determined by the Trustees.
All assets are held in Trust for the purpose of providing benefits to covered Participants and defraying reasonable
administrative expenses. All the benefits are provided on a self-funded basis, except for the Life Insurance Benefit
and Accidental Death and Dismemberment Benefit, which are insured.
24.09 Collective Bargaining Agreement
The Plan is maintained in accordance with a Collective Bargaining Agreement between the Electrical Contractors’
Association of City of Chicago and the Local Union No. 134 International Brotherhood of Electrical Workers. Other
agreements may be in eect from time to time. The agreements specify the contributions required.
The Fund Oce will provide you, upon request, information as to whether a particular Employer is contributing to this
Fund under a Collective Bargaining Agreement or a list of participating Employers.
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24.10 Agent for Service of Legal Process
The agent for service of legal process concerning the Plan is:
Erin Keane
Executive Director
6195 W. 115th Street
Alsip, Illinois 60803
Service of legal process may also be made on the Board of Trustees or any individual Trustee at the addresses listed
under “Board of Trustees.”
24.11 Non-Assignment of Benefits
Generally, benefits from the Plan belong to you. You may not anticipate, alienate, sell, assign, transfer, pledge,
garnish or otherwise encumber any interest in benefits to which you are or may become entitled under the Plan and
any attempt to do so shall be void. No benefits under the Plan shall in any manner be liable for or subject to the debts,
contracts, liabilities, engagements or torts of any person. If any person entitled to benefits under the Plan becomes
bankrupt or attempts to anticipate, alienate, sell, transfer, pledge or garnish any benefit under the Plan, or if any
attempt is made to subject any such benefit to the debts, contracts, liabilities, engagements or torts of the person
entitled to any such benefit, except as specifically provided in the Plan, then such benefit shall cease and terminate
in the discretion of the Trustees, and they may hold or apply the same or any part thereof to the benefit of any eligible
dependent of such person, in such manner and proportion as they may deem appropriate.
24.12 Trustee Authority and Interpretation
The Trustees and/or their delegates have full discretionary authority and expressly reserve the right in their sole and
unrestricted discretion to interpret the terms of the Trust Agreement, this SPD and the procedures of the Plan and
to interpret any facts relevant to the determination, and to determine eligibility and entitlement to benefits. Benefits
under the Plan will be paid only if the Trustees or their delegates decide in their sole and unrestricted discretion
that the Participant or beneficiary is entitled to benefits under the terms of the Plan. The Trustees’ interpretation
is binding on all Participants, Active Employees, Retirees, Dependents and beneficiaries and all other individuals
unless the Trustees’ interpretation is found by a court of competent jurisdiction to be arbitrary and capricious. All
questions or controversies of any type arising in any manner or between any persons in connection with the Plan or its
operations must be submitted to the Trustees or their delegates for decision.
The Trustees, at any time and from time to time, in their sole and unrestricted discretion, have the authority to
increase, decrease or change benefits, eligibility rules or other provisions of the Plan. All benefits of the Plan are
conditional and subject to the Trustees’ authority under the Trust Agreement to change them.
24.13 Severability Clause
If a provision of the Trust Agreement or this SPD or any amendment made to the Trust Agreement or to this SPD is
determined or judged to be unlawful or illegal, such illegality will apply only to the provision in question and will not
apply to any other provisions of the Trust Agreement or SPD.
108
24.14 Pronouns
In this SPD, masculine personal pronouns (he, him, his) include the feminine (she, her, hers) wherever they apply.
Also, wherever the term “you” or “your” is used, it refers to an Active Employee (or Retiree, as applicable), eligible to
receive benefits under the Plan.
24.15 Recovery of Benefits Paid in Error
If for any reason, any benefit paid to a covered person under the Plan is determined to have been in error, or wholly or
partially more than the amount to which such payee was entitled to receive under the Plan, the Trustees may collect
such erroneous benefit payment or overpayment by any remedy as the law may provide.
If any question or dispute arises concerning the proper person or persons to whom any payment will be made under
the Plan, the Trustees may withhold payment until a binding adjudication of the question or dispute is made. The
resolution must be satisfactory to the Trustees in their sole and unrestricted discretion. Alternatively, the Trustees
may pay the benefits if they have been adequately indemnified to their satisfaction against any resulting loss.
24.16 Governing Law
The Plan is governed by federal law, where applicable federal law exists; if there is no applicable federal law, the
internal laws of the State of Illinois will apply in all matters.
24.17 For More Information
All questions and requests for information should be sent to the Trustees at the following address:
Attention: Executive Director
6195 W. 115th Street
Alsip, IL 60803
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109
SECTION 25: GLOSSARY
This section contains definitions of terms used
throughout this booklet. The terms are listed in
alphabetical order.
Active Employee
A person who meets the definition of Employee, who is
actively at work or Available for Work for a contributing
Employer, and who is not a Retiree.
Administrator Program
Programs for which a Hospital has a written agreement
with the Claims Administrator or another Blue Cross
and/or Blue Shield Plan to provide service to you at the
time services are rendered to you. These programs are
limited to a Partial Hospitalization Treatment Program or
Coordinated Home Care Program.
Adverse Benefit Determination
A denial, reduction, or termination of, or a failure to
provide or make payment, in whole or in part, for a
benefit, including a denial, reduction, termination, or
failure to provide or make payment that is based on (1)
a determination of a person’s eligibility to participate
in the Plan (including a rescission of coverage), (2) a
determination that a benefit is not a covered benefit,
(3) the imposition of a source-of-injury exclusion,
network exclusion or other limitation on otherwise
covered benefits, or (4) a determination that a benefit is
Experimental, Investigational or not Medically Necessary
or appropriate.
Affordable Care Act
The Patient Protection and Aordable Care Act, as
amended, and corresponding regulatory and sub
regulatory guidance.
Ambulance Transportation
Local transportation in specially equipped certified
vehicle ground and air ambulance options from your
home, scene of accident or medical emergency to a
Hospital, between Hospital and Hospital, between
Hospital and Skilled Nursing Facility or from a Skilled
Nursing Facility or Hospital to your home. If there are no
facilities in the local area equipped to provide the care
needed, Ambulance Transportation then means the
transportation to the closest facility that can provide the
necessary service. Ambulance Transportation provided
for the convenience of you, your family/caregivers or
Physician, or the transferring facility, is not considered
Medically Necessary and is not covered under the Plan.
Ancillary Services
Emergency medicine, anesthesiology, pathology,
radiology, and neonatology, whether provided by a
Physician or non-Physician practitioner; items and
services provided by assistant surgeons, hospitalists,
and intensivists; diagnostic services, including radiology
and laboratory services; and items and services provided
if there is no Network Provider who can furnish such item
or service at Network facility.
Apprentice School
The Electrical Joint Apprenticeship and Training Trust.
Autism Spectrum Disorder
A pervasive developmental disorder described by the
American Psychiatric Association or the World Health
Organization diagnostic manuals as an autistic disorder,
atypical autism, Asperger Syndrome, Rett Syndrome,
childhood disintegrative disorder, or pervasive
developmental disorder not otherwise specified; or
a special education classification for autism or other
disabilities related to autism.
Available for Work
A non-disabled Participant who has signed the
corresponding IBEW Local 134 Referral Book upon
layo and is compliant with all IBEW Local 134 Referral
procedures as found on the IBEW Local 134 website
(www.lu134.org).
Balance Billing
The dierence between the amount billed by a Non-
Network Provider and the Eligible Charge, which the
Non-Network Provider bills or seeks to recover from the
Participant.
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Billed Charge
The total gross amount billed by your Provider to the
Plan.
Board of Trustees, Trustee or Trustees
The Board of Trustees of the Electrical Insurance
Trustees Health and Welfare Plan for Construction
Workers. The Board of Trustees is both the Plan Sponsor
and Plan Administrator.
Chemical Dependency
Any abuse of, addiction to, or dependency on the use of
drugs, narcotics, alcohol or any other chemical (except
nicotine).
Child(ren)
The biological, adopted, step or foster child. The
definitions of the terms are:
• Biological child: You are shown as a parent on the
child’s birth certificate or paternity order.
• Adopted child: Legally adopted or child placed with
you pending legal adoption.
• Stepchild: Biological (born before your marriage) or
adopted child of your current spouse.
A child for whom you are required to provide health care
due to a QMCSO will also be considered your Child.
Chiropractic and Naprapathic Care
Skeletal adjustments, manipulation or other treatment
(including naprapathy) in connection with the detection
and correction by manual or mechanical means of
structural imbalance or subluxation in the human body.
Treatment is performed to remove nerve interference
resulting from, or related to, distortion, misalignment or
subluxation of, or in, the vertebral column.
Claims Administrator
A neutral third party retained to comply with the
requirements set forth in this Plan and applicable
Medical Policy.
Coinsurance
The percentage of Covered Services you must pay after
you have met your annual Deductible.
Collective Bargaining Agreement
Any applicable collective bargaining agreement now
existing or executed in the future between the Union
and an Employer which provides for contributions to the
Trust Fund, as well as any extensions, amendments, or
renewals thereof.
Contributed Hours
Hours you worked in Covered Employment for which an
Employer made contributions on your behalf to the Fund.
Coordinated Home Care Program
An organized skilled patient care program in which care
is provided in the home. Care may be provided by a
Hospital’s licensed home health department or by other
licensed home health agencies. You must be homebound
(that is, unable to leave home without assistance and
requiring supportive devices or special transportation)
and you must require Skilled Nursing Service on an
intermittent basis under the direction of your Physician,
a physician assistant who has been authorized by a
Physician to prescribe those services, or an advanced
practice nurse with a collaborating agreement with a
Physician that delegates that authority. This program
includes physical, occupational and speech therapists
and necessary medical supplies. The program does not
include and is not intended to provide benefits for Private
Duty Nursing Services or Custodial Care Services. It
also does not cover services for activities of daily living
(personal hygiene, cleaning, cooking, etc.).
Copayment
A specified dollar amount that you are required to pay
towards a Covered Service.
Cosmetic Surgery
Plastic or reconstructive surgery or other services
and supplies which improve, alter or enhance
appearance, whether performed or used for emotional or
psychological reasons.
Covered Employment
Employment of an Active Employee by an Employer for
which contributions to this Fund are required.
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Covered Service
A service, procedure, treatment and/or supply specified
in this benefit booklet for which benefits will be provided.
Credited Service
Credited Service is used to determine the amount of your
pension benefit under Pension Plan No. 2. It also may
be used to determine eligibility for health care coverage
after you retire.
Generally, you receive one full year of Credited Service
for each calendar year in which you have 1,600 hours of
Covered Employment. Before 1976, you received one-
fourth of a year of Credited Service for each 400 hours
you worked during each year — up to the maximum full
year of Credited Service. After 1975, you receive one full
year of Credited Service for each year in which you work
1,600 hours. For each year in which you have at least
400, but fewer than 1,600 hours, you receive Credited
Service in proportion to your number of hours — up to
the maximum full year of Credited Service.
Refer to Pension Plan No. 2 for more information on
Credited Service.
Custodial Care Service
Any service primarily for personal comfort or
convenience that provides general maintenance,
preventive, and/or protective care without any clinical
likelihood of improvement of your condition. Custodial
Care Services also means those services which do not
require the technical skills, professional training and
clinical assessment ability of medical and/or nursing
personnel to be safely and eectively performed. These
services can be safely provided by trained or capable
non-professional personnel, are to assist with routine
medical needs (including but not limited to dressings,
administration of routine medications, ventilator
suctioning and other care) and are to assist with activities
of daily living (including but not limited to bathing, eating
and dressing).
Deductible
The amount you pay for Covered Services each year
before the Plan begins to pay benefits. The deductible
may not apply to all Covered Services.
Dentist
A person licensed to practice dentistry by the
governmental authority having jurisdiction over the
license and practice of dentistry and who is acting within
the scope of that license.
Dependent
A person who is:
• A Participant’s lawful spouse (i.e., the person legally
married to the Employee or Retiree)
• Each Child of a Participant from the date he or she
first becomes a Child of the Participant to the end of
the month in which such attains age 26
• A Child who has been diagnosed with severe physical
or mental disability, and the disability is expected to
last for a continuous period of 12 months or more,
provided:
– Such incapacity began before the end of the
month such Child attains age 19
– Such Child was covered by the Plan on the day
prior to his or her 19th birthday
– Such Child is dependent on the Employee or
Retiree for more than 50% of his or her financial
support and maintenance for the calendar year
– Such Child resides with the Employee or Retiree
– Such Child’s disability is not solely due to
alcoholism or drug addiction.
The Trustees may request the Employee or Retiree
provide proof of the Child’s disability, including that
he became disabled before reaching age 26 and
annual proof of the Child’s continued disability. It is the
responsibility of the Employee or Retiree to provide all
proof of disability at his or her own expense. If the proof
is not provided when required, the Child’s eligibility for
coverage under the Plan as a Dependent will terminate.
Any Dependent you acquire after your Retirement Date is
not eligible for Retiree Health Benefits.
Designated Beneficiary
The person you designate on the beneficiary designation
form is available from the Fund Oce. Your Designated
Beneficiary applies to both the Life Insurance Benefit
and the AD&D Benefit. A beneficiary designation form is
valid upon receipt by the Fund Oce before your death.
112
Disabled
If you suer from an illness or accidental injury that
prevents you from being continuously able to perform
your job, and you are under the care of a Physician or
licensed behavioral health provider.
Durable Medical Equipment
Equipment that (1) can withstand repeated use, (2)
is primarily and customarily used to serve a medical
purpose related to the person’s physical disorder, (3)
generally is not useful in the absence of illness or injury,
and (4) is appropriate for use in the home.
Examples of Durable Medical Equipment covered
under the Plan include, but are not limited to, the
following: glucose and apnea monitoring devices,
transneuromuscular stimulators, wheelchairs, manually
operating hospital beds and oxygen machines.
Examples of equipment that are not Durable Medical
Equipment and are not covered under the Plan include,
but are not limited to, the following: exercise and sports
equipment, wheelchair lifts, extended warranties, air
cleaners, air purifiers, vacuum systems and filters.
Eligible Charge
The amount of expenses billed by a Provider that
is covered under the Plan, subject to all applicable
limitations and restrictions.
For a Network Provider, the Eligible Charge is the
negotiated fee or rate set forth in the Plan’s agreement
with the participating network, health and/or dental
provider, facility or organization.
For medical services from a Non-Network Provider,
the Eligible Charge shall be the lesser of (a) the
Provider’s Billed Charges, or (b) an amount determined
by BCBSIL to be approximately 100% of the base
Medicare Reimbursement Rate, excluding any Medicare
adjustment(s) which is/are based on information on the
claim; or (ii) if there is no base Medicare Reimbursement
Rate available for a particular Covered Service, or if
the base Medicare reimbursement amount cannot
otherwise be determined under (i) above based upon the
information submitted on the claim, the lesser of (a) the
Provider’s Billed Charges and (b) an amount determined
by the Claims Administrator to be 100% of the maximum
allowed if the services were rendered by a Network
Provider on the date of service; or (iii) if the base
Medicare reimbursement amount and the Eligible Charge
cannot be determined under (i) or (ii) above, based upon
the information submitted on the claim, then the amount
will be 100% of the Provider’s Billed Charges; provided,
however, that the Claims Administrator may limit such
amount to the lowest contracted rate that the Claims
Administrator has with a Network Provider for the same
or similar services based upon the type of provider and
the information submitted on the claim, as of January 1
of the same year that the Covered Services are rendered
to the covered person.
For all other services from a Non-Network Provider, the
Eligible Charge is the amount as determined by the Board
of Trustees for a particular service or supply.
Emergency Medical Condition
A bodily injury or sickness, including a mental health
condition or substance use disorder, manifesting itself by
acute symptoms of sucient severity (including severe
pain) such that a prudent layperson, who possesses
an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical
attention would result in placing the health of the
individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious
jeopardy, serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part.
Emergency Services
With respect to an Emergency Medical Condition means:
• A medical screening examination that is within the
capability of the emergency department of a hospital
or of an independent freestanding emergency
department, as applicable, including
Ancillary Services routinely available to the
emergency department to evaluate such emergency
medical condition; and
• Medical examination and treatment that are within
the capabilities of the sta and facilities available
at such hospital or independent freestanding
emergency department, as applicable, to Stabilize
the patient (regardless of the department of the
SUMMARY PLAN
DESCRIPTION
113
hospital in which such further examination or
treatment is furnished); and
• Unless the covered individual’s consent to Non-
Network services is provided to the Plan by the
provider or facility, items and services for which
benefits are provided by the Plan that are furnished
by a Non-Network provider or Non-Network
emergency facility after the covered individual is
Stabilized and as part of outpatient observation or
an inpatient or outpatient stay with respect to the
Emergency Medical Condition which gave rise to the
initial Emergency Services.
Employee
An individual who is working in Covered Employment
and is eligible for benefits under the Plan. In connection
with Retiree Benefits, Employee also means a Retiree
who is eligible for Retiree Benefits as the context deems
appropriate.
Employer
An association or corporation that has a Collective
Bargaining Agreement with the Union that requires
contributions to the Plan. The Fund, the Union and the
fringe benefit funds associated with the Union are also
considered to be Employers with regard to their own
employees. As the context deems appropriate, Employer
also includes an association, corporation or organization
that has entered into a participation agreement with the
Trustees to make contributions to the Plan on behalf
of employees who are not covered under a Collective
Bargaining Agreement.
ERISA
The Employee Retirement Income Security Act of 1974,
as amended.
Experimental or Investigational
Treatment, procedures, facility, equipment, drugs,
devices, services and/or supplies which are not accepted
as Standard Medical Treatment for the condition being
treated or, if any such items required federal or other
governmental agency approval, such approval was not
granted at the time services were provided. Standard
Medical Treatment means the services or supplies that
are in general use in the medical community in the
United States and:
• have been demonstrated in peer reviewed literature
to have scientifically established medical value for
curing or alleviating the condition being treated;
• are appropriate for the Hospital or Facility in which
they are performed; and
• the Physician or Professional Provider has had the
appropriate training and experience to provide the
treatment or procedure.
The Trustees have the authority to determine whether a
service, procedure drug, device or treatment modality is
Experimental or Investigational. The fact that a Physician
has prescribed, ordered, recommended or approved the
service, procedure, drug, device or treatment does not,
in itself, make it eligible for payment.
Fund Office
The administrative oce for the Fund located at 6195 W.
115th Street, Alsip, Illinois 60803.
Hospice Care Program Provider
An organization duly licensed to provide Hospice Care
Program Service, when operating within the scope of
such license.
Hospice Care Program Service
A centrally administered program designed to provide
physical, psychological, and spiritual care for dying
people and their families. Hospice Care Program Service
is available in the home, Skilled Nursing Facility, or
special hospice care unit.
Hospital
A lawfully operating institution for the care and treatment
of sick and injured persons with organized facilities for
diagnosis and treatment, medical supervision, 24-hour
nursing service by registered nurses, and surgery (or
provides for surgical facilities on a formal arrangement).
In no event, however, does the term Hospital include
any institution or part of an institution which is used
principally as a rest facility or facility for the aged, nor
does it include a hospital operated by the United States
Government, unless the claimant is required to pay such
expense.
114
Inpatient
A person who is a registered bed patient and is treated as
such in a health care facility.
Maintenance Care
Services administered to a Participant or Dependent to
maintain a level of function at which no demonstrable
and/or measurable improvement of condition will occur.
This includes Occupational, Physical and Speech
Therapy.
Medically Necessary
A specific medical, health care, supply or Hospital
service that is required for the treatment or management
of a medical symptom or condition, and that the service,
supply or care provided is the most ecient and
economical service which can safely be provided.
The fact that your Physician may prescribe, order,
recommend, approve or view hospitalization or
other health care services and supplies as Medically
Necessary, does not make the hospitalization, services
or supplies Medically Necessary and does not mean the
Claims Administrator will approve and pay the cost of the
hospitalization, services or supplies.
Only those services, supplies and treatments that, in
the judgement of the Trustees based on the opinion
of a medical professional who is qualified to render an
opinion on the issue, meet all the following conditions:
• Provided by a licensed provider, acting with the
scope of his or her license;
• Required to identify or treat an injury or sickness;
• Not Experimental or Investigational;
• Consistent in type, frequency and duration of
treatment with scientifically based guidelines of
national medical, research or health care coverage
organizations or governmental agencies;
• Consistent with the symptoms or diagnosis of the
patient’s condition; and
• Required for reasons other than the convenience of
the patient or Physician.
Medical Care
The ordinary and usual professional services rendered
by a Physician or other specified Provider during a
professional visit for treatment of an illness or injury.
Medical Policy
The guidelines used by the Claims Administrator for
determining if a service, procedure, treatment or supply
is Medically Necessary.
Medicare Reimbursement Rate
A listing of fees developed by the Centers for Medicare
and Medicaid Services and used by Medicare to
determine appropriate payment for providers or suppliers
of medical care and treatment.
Mental or Nervous Disorder
A condition or disorder that involves a mental health
condition or Substance Use Disorder that falls under
any of the diagnostic categories listed in the mental and
behavioral disorders chapter of the current edition of the
International Classification of Disease or that is listed in
the most recent version of the Diagnostic and Statistical
Manual of Mental Disorders.
Morbid Obesity
A condition that exists when weight is at least twice the
ideal weight for frame, age, height and gender according
to the Federal Guidelines on Obesity.
Network Pharmacy
A pharmacy who participates in the CVS/Caremark
network of pharmacies. The Plan currently contracts
with CVS/Caremark and its network of pharmacies, and
prescriptions purchased through a Network Pharmacy
are covered under the Plan.
Network Provider
A Provider who participates in a Preferred Provider
Organization (PPO) by agreeing to accept certain pre-
determined, negotiated and discount rates or fees
for health care services provided. The Plan contracts
with a PPO to provide access to Network Providers to
participants. You will maximize your benefits when you
visit a provider in the PPO network with which the Plan
contracts.
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DESCRIPTION
115
No Surprises Act
The federal No Surprises Act (Public Law 116-260,
Division BB), and corresponding regulatory and sub-
regulatory guidance.
Non-Network Pharmacy
A pharmacy who does not participate in the CVS/
Caremark network of pharmacies. Prescriptions
purchased at a Non-Network Pharmacy are not covered
under the Plan.
Non-Network Provider
A Provider that does not participate in a Preferred
Provider Organization (PPO) with which the Plan
contracts. These providers have not agreed to accept a
PPO Negotiated Rate for their services covered under
the Plan. If you choose to receive services from a Non-
Network Provider, the Plan will pay a percentage of
charges for Covered Services, based on the Eligible
Charges (not the Billed Charges), and the Non-Network
Provider may choose to balance bill you for any
dierence between the Eligible Charges and the Billed
Charges, except as required by the No Surprises Act.
Outpatient
Receiving treatment while not an Inpatient. Services
considered Outpatient, include, but are not limited to,
services in an emergency room regardless of whether
you are subsequently registered as an Inpatient in a
health care facility.
Partial Hospitalization Treatment Program
A Claim Administrator approved planned program of a
Hospital or Substance Use Disorder Treatment Facility
for the treatment of Mental Illness or Substance Use
Disorder Treatment in which patients spend days or
nights. This behavioral healthcare is typically 5 to
8 hours per day, 5 days per week (not less than 20
hours of treatment services per week). The program
is staed similarly to the day shift of an Inpatient unit,
i.e., medically supervised by a Physician and nurse. The
program shall ensure a psychiatrist sees the patient face
to face at least once a week and is otherwise available,
in person or by telephone, to provide assistance and
direction to the program as needed. Participants at this
level of care do not require 24-hour supervision and are
not considered a resident at the program.
The Claim Administrator requires that any Mental Illness
and/or Substance Use Disorder Partial Hospitalization
Treatment Program must be licensed in the state where
it is located or accredited by a national organization that
is recognized by the Claim Administrator as set forth in
its current credentialing policy, and otherwise meets all
other credentialing requirements set forth in such policy.
Participant
An Employee or Retiree who is eligible and covered under
the Plan.
Pension Plan No. 2
The Electrical Contractors Association and Local Union
134 I.B.E.W. Joint Pension Trust of Chicago Pension Plan
No. 2.
Pension Plan No. 5
The Electrical Contractors Association and Local Union
134 I.B.E.W. Joint Pension Trust of Chicago Pension Plan
No. 5.
Pharmacy Benefits Manager (PBM)
A third-party administrator of the prescription drug
program that is primarily responsible for processing and
paying prescription drug claims under the terms of the
Plan.
Physician
A medical practitioner who is licensed to practice
medicine, perform surgery, and administer drugs under
the laws of the state or jurisdiction where the services
are rendered, and who is acting within the scope of that
license.
Plan
The Electrical Insurance Trustees Health and Welfare
Plan for Construction Workers.
Plan Administrator
The Board of Trustees of the Electrical Insurance
Trustees Health and Welfare Plan for Construction
Workers. The Plan Administrator controls and manages
the operation and administration of the benefits and
programs of the Plan.
116
PPO Negotiated Rate
The amount for services and supplies, as negotiated
between the Network Provider and the PPO network,
that the Network Provider has agreed to accept as full
payment for services. For services provided by a Network
Provider, the PPO Negotiated Rate is the Eligible Charge
under the Plan.
Preferred Provider Organization (PPO)
A medical organization that allows you to choose from
a list of Network Providers. A PPO is comprised of a
network of Hospitals, Physicians and other health care
providers, which have agreed to provide health care
services to Participants of the Plan for a pre-determined
and discounted fee or rate.
Preventive Services
• Evidence-based items or services that have in eect
a rating of A or B in the current recommendations
of the United States Preventive Services Task Force
with respect to the individual involved;
• Immunizations for routine use in children,
adolescents and adults that have a recommendation
in eect from the Advisory Committee on
Immunization Practices of the Centers for Disease
Control and Prevention with respect to the individual
involved (for this purpose, a recommendation from
the Advisory Committee on Immunization Practices
of the Centers for Disease Control and Prevention
is considered in eect after it has been adopted by
the Director of the Centers for Disease Control and
Prevention, and a recommendation is considered to
be for routine use if it is listed on the Immunization
Schedules of the Centers for Disease Control and
Prevention);
• With respect to infants, children and adolescents,
evidence-informed preventive care and screenings
provided for in comprehensive guidelines
supported by the Health Resources and Services
Administration; and
• With respect to women, to the extent not described
above, evidence-informed preventive care and
screenings provided for in comprehensive guidelines
supported by the Health Resources and Services
Administration.
Provider
Any health care facility (for example, a Hospital or Skilled
Nursing Facility) or person (for example, a Physician or
Dentist) or entity licensed to render Covered Services
to a Participant and operating within the scope of such
license.
• Participating Provider – an administrator Hospital
or Professional Provider which has a written
agreement with the Claims Administrator or another
aliated plan to provide services to you in the
Preferred Provider Organization (PPO) program or an
administrator facility which has been designated by
the Claims Administrator as a Participating Provider.
• Non-Participating Provider – an administrator
Hospital or Professional Provider which does
not have a written agreement with the Claims
Administrator or another aliated plan to
provide services to you in the Preferred Provider
Organization (PPO) program or a facility which has
not been designated by the Claims Administrator as
a Participating Provider.
• Professional Provider – a Physician, Dentist,
podiatrist, psychologist, chiropractor, optometrist, or
any Provider designated by the Claims Administrator
or aliated plan.
Qualified Medical Child Support Order (QMCSO)
A judgment, decree or order issued under a state
domestic relations law by a court of competent
jurisdiction that requires a parent to provide medical
support to a child.
Qualifying Event
Certain events that cause you and/or your covered
Dependents to lose coverage under the Plan and
become eligible for COBRA coverage. Qualifying Events
include the death of a Participant, a reduction of the
Participant’s hours or loss of employment (except due
to gross misconduct), the Participant’s entitlement
to Medicare benefits, a Dependent losing his or her
Dependent status under the Plan, and legal separation or
divorce from the Participant.
SUMMARY PLAN
DESCRIPTION
117
Qualifying Payment Amount (QPA)
The median contracted rate on January 31, 2019, as
adjusted, for the same or similar item or service that is
provided by a Provider in the same or similar specialty
and provided in a geographic region in which the item or
service is furnished, increased for inflation.
Referral Hall
The Union oce where members must register their
availability for work and from where employment is
assigned.
Residential Treatment Center
A facility setting oering a defined course of therapeutic
intervention and special programming in a controlled
environment which also oers a degree of security,
supervision, structure and is licensed by the appropriate
state and local authority to provide such service. It does
not include halfway houses, supervised living, group
homes, wilderness programs, boarding houses or other
facilities that provide primarily a supportive environment
and address long-term social needs, even if counseling
is provided in such facilities. Patients are medically
monitored with 24-hour medical availability and onsite
nursing care and supervision for at least one shift a day
with on call availability for other shifts for patients with
Mental Illness and/or Substance Use Disorders. The
Claim Administrator requires that any Mental Illness
and/or Substance Use Disorder Residential Treatment
Center must be licensed in the state where it is located or
accredited by a national organization that is recognized
by the Claim Administrator as set forth in its current
credentialing policy and otherwise meets all other
credentialing requirements set forth in such policy.
Residential Treatment Center (RTC) programs/services
for the treatment of Mental Illness and/or Substance
Use Disorders that do not provide 24-hour medical
availability and that do not provide on-site nursing care
and supervision for at least one shift a day with on call
availability for other shifts are not considered Medically
Necessary.
Retiree
An individual who formerly worked in Covered
Employment and who is eligible for Retiree Health
Benefits.
Retiree Interim Coverage
Retiree Interim Coverage is an extension of COBRA
coverage for an additional six months to bridge health
care for members who retire at age 60 and meet the
requirements for Retiree Health Benefits.
Retirement Date
The eective date of your retirement benefit under
Pension Plan No. 2.
Review Quarter
The three-month period running from January through
March, April through June, July through September
or October through December, as the context deems
appropriate.
Skilled Nursing Facility
A licensed facility that provides 24-hour professional
nursing services on an inpatient basis to persons
convalescing from injury or sickness. Skilled Nursing
Facilities maintain a complete medical record on each
service recipient and are supervised on a full-time basis
by a Physician.
Stabilize(d)
With respect to an Emergency Medical Condition, that no
material deterioration of the condition is likely to result
for or occur during the transfer of the individual from a
facility.
Substance Abuse Disorder
A condition or disorder that falls under any of the
substance use disorder diagnostic categories listed in
the mental and behavioral disorder chapter of the current
edition of the International Classification of Disease or
that is listed in the most recent version of the Diagnostic
and Statistical Manual of Mental Disorder.
Surgery
The performance of any medically recognized, non-
Investigational surgical procedure including the use
of specialized instrumentation and the correction
of fractures or complete dislocations and any other
procedures as reasonably approved by the Claims
Administrator.
118
Trust Agreement
The Agreement and Declaration of Trust that establishes
the Plan, including all amendments, establishing the
Trust Fund and its rule of operation and known as the
Insurance Trust Agreement between the Electrical
Contractors’ Association of the City of Chicago and the
Local Union 134 I.B.E.W.
Union
The Local Union No. 134 International Brotherhood
of Electrical Workers (I.B.E.W.), AFL-CIO and any
successors.
Usual and Customary Rate (U&C)
The charges considered appropriate in your geographic
area for Medically Necessary services, treatments,
supplies or drugs.
Welfare Fund or Fund
Refers to the assets held in trust for the EIT Benefit
Funds Health and Welfare Plan for Construction Workers.
6195 West 115th Street
Alsip, IL 60803
(312) 782-5442
